Randomized double-blinded trial investigating the impact of a curriculum focused on error recognition on laparoscopic

suturing training

J Bingener, T Boyd, K Van Sickle, I Jung, A Saha, J Winston, P Lopez, H Ojeda, W Schwesinger, D Anastakis

Background

• Laparoscopic intracorporeal suturing not easy to learn

• Best learned outside patient care setting

• Computer and box training tools

Background• Suturing skills – imitation learning

• “ this is how I do it” - “don’t do it like this”

• Knowledge based errors

Surgical skill is predicted by the ability to detect errors

(Bann S et al. Am J Surg 189 (2005) 412-415)

Error detection on 22 models presented

Ob

serv

ed

surg

ica

l ski

ll (O

SA

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)

Question

Will the inclusion of an error recognition module in the laparoscopic suturing curriculum

• enable error recognition and

• improve the technical proficiency of the learner?

Study design

• Study population:

• 30 novices

• randomized to

A: control group

B: intervention group

• Learners blinded to group assignment

• Video-instruction for laparoscopic suturing

Group A

Pretest:

Error counting video (3)

Suturing practice

Suturing task time

post test:

suturing task time

OSATS video score

Error recognition video (2)

Questionnaire Suturing video (1)

Error counting video (3)

OSATS video score

post test:

OSATS video score

Group B

Suturing practice

Suturing task time

Study design

• No feed-back during study

• Same investigator

• Study period: 2 summer months

• Time line

Group A Group B

Metrics

• Pre and post training laparoscopic suturing task time (seconds)

• Pre and post training OSATS score (1-5)

• Post training error recognition score (% errors recognized in video compared to experts)

Reviewer preparation

• Reviewers watched novice and expert video for “calibration”

• Blinded to group assignment • Independent review after study period

• Kendall’s Tau for correlation0.6 <τ <0.99

DemographicsGroup B Group A

Gender Female 8 (53.3) 4 (26.7)

Male 7 (46.7) 11 (73.3)

Total 15 15

P-value1 0.264

Video game

Novice 11 (73.3) 5 (33.3)

Intermediate 4 (26.7) 6 (40)

Experienced 0 (0) 4 (26.7)

Total 15 15

P-value1 0.031

Results – Task Time

Group A (SE) Group B (SE)

Task time difference

(SE) P-value

Pretest task time (sec)

521 (27.74) 535.5 (18.69) 14.5 (32.68) 0.658

Posttest task time (sec)

337.7 (29.04) 462.3 (30.36) 124.5 (41.4) 0.003

Task time Difference (sec)

-183.3 (23.71) -73.2 (22.11)

P-value <.001 0.001

Task Time by covariates

Gamer Level 1

Control (Female)Control (Male)Variable (Female)Variable (Male)

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Gamer Level 2

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Gamer Level 3

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Mean overall OSATS scores

Group A Group B Difference P-value

Pretest 1.6 (0.13) 1.7 (0.13) 0.1 (0.19) 0.784

Posttest 2.3 (0.13) 2.2 (0.13) -0.1 (0.19) 0.558

Difference 0.7 (0.06) 0.5 (0.06)

P-value <.001 <.001

1.0

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Mean OSATS scores for task forward flow Mean OSATS scores for instrument handling

p=0.63

P=0.53

OSATS sub-scores

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Mean OSATS scores for respect for tissue

Mean OSATS scores for time motion efficiency

Mean OSATS scores for knowledge of task

p=0.066

p=0.62

p=0.43

Errors recognized (video 3)Group A

Control Group (n=15)

Group B Error Recognition

Group (n=15)

#Errors (%) #Errors (%) P-value

No C Loop 2 (13.3) 10 (66.7) 0.008

No surgeons knot

(wrapped once)

11 (73.3) 13 (86.7) 0.651

No square knot (didn’t switch hands)

12 (80) 8 (53.3) 0.245

Total 2 (0, 4) 4 (1, 7) <.001

Results - summary

• Additional error recognition teaching

– Slowed down learner in task performance– Did not change OSAT scores– Led to cognitive error recognition

Visual information overload?

Error pattern

Corrrect pattern

Incorrect pattern

Group B

Group A

•Timing of error teaching module•Time to practice•Repetitive practice•Separate days

Attentional capacity threshold

Use of Attentional Resources

Novice surgeon Pre-trained Novice Master surgeon

Attentionalresources

Psychomotorperformance

Comprehending Attendinginstruction

Gaining additionalknowledge

Depth & Spatialjudgments

Judgement &Decision making

Gallagher et al

Future Research Directions

• Modify instruction timing

• Modify learner group (pre-trained novice/ intermediate learner)

• Use video-game experience as randomization criterion

Thank you