1. 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

2. Background Laparoscopic intracorporeal suturing not easy to learn Best learned outside patient care setting Computer and box training tools

3. Background Suturing skills – imitation learning “ this is how I do it” - “don’t do it like this” Knowledge based errors

4. 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 Observed surgical skill (OSATS)

5. 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?

6. Study design Study population: 30 novices randomized to A: control group B: intervention group Learners blinded to group assignment Video-instruction for laparoscopic suturing

7. 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

8. Study design No feed-back during study Same investigator Study period: 2 summer months Time line Group AGroup B

9. 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)

10. Reviewer preparation Reviewers watched novice and expert video for “calibration” Blinded to group assignment Independent review after study period Kendall’s Tau for correlation 0.6 <τ <0.99

11. Demographics Group BGroup A GenderFemale8 (53.3)4 (26.7) Male7 (46.7)11 (73.3) Total15 P-value 1 0.264 Video game Novice11 (73.3)5 (33.3) Intermediate4 (26.7)6 (40) Experienced0 (0)4 (26.7) Total15 P-value 1 0.031

12. 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<.0010.001

13. Task Time by covariates

14. Mean overall OSATS scores Group AGroup BDifferenceP-value Pretest1.6 (0.13)1.7 (0.13)0.1 (0.19)0.784 Posttest2.3 (0.13)2.2 (0.13)-0.1 (0.19)0.558 Difference0.7 (0.06)0.5 (0.06) P-value<.001

15. Mean OSATS scores for task forward flow Mean OSATS scores for instrument handling p=0.63 P=0.53 OSATS sub-scores

16. 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

17. Errors recognized (video 3) Group A Control Group (n=15) Group B Error Recognition Group (n=15) #Errors (%) P-value No C Loop2 (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 Total2 (0, 4)4 (1, 7)<.001

18. Results - summary Additional error recognition teaching –Slowed down learner in task performance –Did not change OSAT scores –Led to cognitive error recognition

19. 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

20. Attentional capacity threshold Use of Attentional Resources Novice surgeonPre-trained NoviceMaster surgeon Attentional resources Psychomotor performance Comprehending Attending instruction Gaining additional knowledge Depth & Spatial judgments Judgement & Decision making Gallagher et al

21. Future Research Directions Modify instruction timing Modify learner group (pre-trained novice/ intermediate learner) Use video-game experience as randomization criterion

22. Thank you