Systematic review of measurement tools to assess surgeons' intraoperative cognitive workload

Objective Assessment of Cognitive Workload in Surgery: A Systematic Review

OBJECTIVE

To systematically review technologies that objectively measure cognitive workload (CWL) in surgery, assessing their psychometric and methodological characteristics.

BACKGROUND

Surgical tasks involving concurrent clinical decision-making and the safe application of technical and non-technical skills require a substantial cognitive demand and resource utilization. Cognitive overload leads to impaired clinical decision-making and performance decline. Assessing CWL could enable interventions to alleviate burden and improve patient safety.

METHODS

Ovid MEDLINE, OVID Embase, the Cochrane Library, and IEEE Xplore databases were searched from inception to August 2023. Full-text, peer-reviewed original studies in a population of surgeons, anesthesiologists or interventional radiologists were considered, with no publication date constraints. Study population, task paradigm, stressor, cognitive load theory (CLT) domain, objective and subjective parameters, statistical analysis, and results were extracted. Studies were assessed for (1) definition of CWL; (2) details of the clinical task paradigm; and (3) objective CWL assessment tool. Assessment tools were evaluated using psychometric and methodological characteristics.

RESULTS

A total of 10,790 studies were identified; 9004 were screened; 269 full studies were assessed for eligibility, of which 67 met inclusion criteria. The most widely used assessment modalities were autonomic (32 eye studies and 24 cardiac). Intrinsic workload (eg, task complexity) and germane workload (effect of training or expertize) were the most prevalent designs investigated. CWL was not defined in 30 of 67 studies (44.8%). Sensitivity was greatest for neurophysiological instruments (100% EEG, 80% fNIRS); and across modalities accuracy increased with multisensor recordings. Specificity was limited to cardiac and ocular metrics, and was found to be suboptimal (50% and 66.67%). Cardiac sensors were the least intrusive, with 54.2% of studies conducted in naturalistic clinical environments (higher ecological validity).

CONCLUSIONS

Physiological metrics provide an accessible, objective assessment of CWL, but dependence on autonomic function negates selectivity and diagnosticity. Neurophysiological measures demonstrate favorable sensitivity, directly measuring brain activation as a correlate of cognitive state. Lacking an objective gold standard at present, we recommend the concurrent use of multimodal objective sensors and subjective tools for cross-validation. A theoretical and technical framework for objective assessment of CWL is required to overcome the heterogeneity of methodological reporting, data processing, and analysis.

ErgoEd: a pre-post trial investigating the effect of ergonomic education on laparoscopic surgeons' ergonomic risk scores

This pre-post trial investigates whether ergonomic education using the STEPS model (Screen, Table, Equipment, Posture, Stance) can improve laparoscopic surgeons' ergonomic risk. Intraoperative photographs taken at 1-min intervals were used to calculate risk through the objective Rapid Entire Body Assessment (REBA) scale. Surgeons were reobserved immediately after an educational video, then again 4-6 weeks later. Cognitive strain (modified NASA-TLX), subjective outcomes, and knowledge retention were also assessed. Ten surgeons were recruited from colorectal, general, and gynaecology. There was no difference in REBA between baseline (REBA ​= ​5.0) and early reobservation (REBA ​= ​4.5) [0 ​= ​0.058], but between baseline and late reobservation (REBA ​= ​4.5) there was a significant reduction [p ​= ​0.028]. The overall scores for each day remained in the "medium risk" category. Knowledge retention was good (90 ​% correct answers). All found the education worthwhile and subsequently made changes to their practice. Ergonomic education is desired and deemed very important by surgeons, and reduces both their ergonomic risk and subjective experience of pain, but laparoscopic surgery remains ergonomically "medium risk" overall. Further solutions must be found to reduce risk.

Virtual Reality Simulation as a Tool for ENT Training: An Autoethnographic Study

OBJECTIVE

To investigate the factors influencing a novice trainee's surgical skill acquisition using virtual reality (VR) temporal bone (TB) drilling simulation as a training tool. This study is the first application of autoethnography in the surgical simulation literature.

DESIGN

This study uses autoethnography to examine the factors underpinning simulated surgical skill acquisition using VR TB drilling (ethnography) through systematically documenting and analyzing the researcher's reflections over a prolonged period of time (autobiography). The primary researcher undertook 16 3-hour sessions learning to perform a virtual cortical mastoidectomy on the Voxel-Man TempoSurg (VMT) simulator over 8 months. Data collected comprised qualitative field notes and reflective journal logs, and quantitative scores from formative assessments. Data were coded using NVivo12 and analyzed using inductive thematic analysis.

SETTING

University Hospitals Birmingham ENT Simulation Dry Lab, Queen Elizabeth Hospital, Birmingham, United Kingdom.

PARTICIPANTS

The primary researcher, a surgical novice, was responsible for the study design and execution, with supervision from a consultant ENT surgeon and 2 simulation fellows.

RESULTS

The study yielded 6 themes: About 3 themes highlight new insights: 1) VMT as a surgical learning tool, 2) overcoming technological issues, 3) and physical impacts of simulated surgery; About 3 themes support existing evidence relating to surgical skill acquisition: 4) rushing leading to inaccuracy, 5) reflections and feedback, and 6) overcoming demotivation.

CONCLUSION

The application of autoethnography to the study of surgical skill acquisition is new. Our results enable a deeper insight into surgical skill acquisition using VR TB simulation, with 6 specific themes identified as impacting learning with this tool. An understanding of these factors will facilitate future research in this area, and enable constructive adjustments to the learning experience, ultimately improving training program delivery and outcomes going forward.

Association Between Surgeon Stress and Major Surgical Complications

Importance

Surgeon stress can influence technical and nontechnical skills, but the consequences for patient outcomes remain unknown.

Objective

To investigate whether surgeon physiological stress, as assessed by sympathovagal balance, is associated with postoperative complications.

Design, Setting, and Participants

This multicenter prospective cohort study included 14 surgical departments involving 7 specialties within 4 university hospitals in Lyon, France. Exclusion criteria consisted of patient age younger than 18 years, palliative surgery, incomplete operative time-stamping data, procedures with a duration of less than 20 minutes, and invalid surgeon heart rate variability (HRV) data. Data were accrued between November 1, 2020, and December 31, 2021, with 30-day follow-up completed on May 8, 2022. Analyses were performed from January 1 to May 31, 2024.

Exposure

Sympathovagal balance of the attending surgeon in the first 5 minutes of surgery.

Main Outcomes and Measures

Major surgical complications, extended intensive care unit stay, and mortality within 30 days, after adjustment via mixed-effects multivariable logistic regression for surgeon age, professional status, the time of incision, the random effect of the surgeon, and a composite risk score incorporating patient comorbidities and surgery characteristics. Sympathovagal balance was quantified by the low frequency to high frequency (LF:HF) ratio derived from HRV data measured by chest monitors worn intraoperatively. The LF:HF ratio was normalized at the surgeon level to the median value observed for each surgeon during the study period to control for baseline differences.

Results

A total of 793 surgical procedures performed by 38 attending surgeons were included in the analysis. Median patient age was 62 (IQR, 47-72) years, and 412 (52.0%) were female, with a median of 2 (IQR, 1-4) comorbidities. Median surgeon age was 46 (IQR, 39-52) years, 39 (78.9%) were male, and 22 (57.9%) were professors. Median surgeon heart rate was 88 (IQR, 77-99) beats per minute. Median surgeon LF:HF ratio was 7.16 (IQR, 4.52-10.72) before and 1.00 (IQR, 0.71-1.32) after normalization. Increased surgeon sympathovagal balance during the first 5 minutes of surgery was associated with significantly reduced major surgical complications (adjusted odds ratio [AOR], 0.63; 95% CI, 0.41-0.98; P = .04), though not with reduced intensive care unit stay (AOR, 0.34; 95% CI, 0.11-1.01; P = .05) or mortality (AOR, 0.18; 95% CI, 0.03-1.03; P = .05).

Conclusions and Relevance

Increased surgeon stress at the beginning of a procedure was associated with improved clinical patient outcomes. The results are illustrative of the complex relationship between physiological stress and performance, identify a novel association between measurable surgeon human factors and patient outcomes, and may highlight opportunities to improve patient care.

Influence of radiation personal protection equipment design on surgeon stress-A randomised repeated-measures crossover study

INTRODUCTION

Radiation Personal Protective Equipment (RPPE) is the subject of safety guidance from the British Orthopaedic Association (BOA). This pilot study aimed to examine potential performance differences in Trauma and Orthopaedic (T&O) Higher Surgical Trainees (HST) undertaking simulated Dynamic Hip Screw (DHS) surgery related to different RPPE attire.

METHODS

Fourteen Higher Surgical Trainees took part in a randomised, repeated-measures, crossover study (8 male, 6 female HSTs) performing two simulated DHS procedures wearing two RPPE attire styles (One Piece (OP) tabard 0.35 mm thickness, and Two-Piece skirt/top (TP), with a 0.5 mm thyroid guard). Primary outcome measures included continuous Heart Rate (HR) monitoring, body temperature, and Visual Analogue Scales (VAS) for comfort and fatigue before and after simulations.

RESULTS

Mean (SD) HR in OP and TP were HR OP 98.8 bpm (10.3) vs. TP 98.1 bpm (10.8, p < 0.001), Maximum HR OP 115.1 bpm (SD 12.4) vs. TP 113.4 bpm (SD 11.9) (p < 0.001). Mean change in temperature were OP 0°C and TP -0.03 °C (p < 0.001). Mean temperature VAS scores in OP were 1.9 (1.7) vs. TP 2.0 (1.4, p < 0.001). Mean Comfort VAS scores were OP 3.1 (2.4) vs. TP 1.7 (2.1, p < 0.001) and Fatigue OP 1.4 (1.9) vs. TP 0.8 (1.5, p = 0.120).

DISCUSSION

Important differences in surgeon physiological measures (HR, temperature) and self-reported measures of comfort and temperature were found related to RPPE style. Understanding the effects that specific RPPE attire has on performance should influence RPPE choice and the findings help inform future research into this important topic.

Short-term outcomes of preoperative computed tomography angiography versus standard assessment in patients with BMI ≥ 25.0 kg/m2 undergoing laparoscopic gastrectomy: the GISSG20-01 randomized clinical trial

BACKGROUND

Laparoscopic gastrectomy lacks hand-direct tactile sense and has a limited surgical field compared to laparotomy. Apart from textbook classification, there are anatomical variations in the gastric arteries. Laparoscopic gastrectomy presents technical difficulties and necessitates a more comprehensive comprehension of regional anatomy than open surgical procedures. We aimed to compare efficacy and safety of preoperative computed tomography angiography (CTA) associated with surgical decision-making for laparoscopic gastrectomy.

METHODS

The GISSG 20-01 study was a multicenter, open-label, randomized clinical trial. The enrollment criteria mainly included histologically confirmed gastric cancer patients with BMI ≥ 25 kg/m2. Eligible patients were randomly assigned to the CTA group or the non-CTA group in a 1:1 ratio. The primary endpoint was the volume of intraoperative blood loss.

RESULTS

Between November 2020 and December 2021, 382 patients were enrolled and randomly assigned. After exclusion of 25 patients, 357 patients were included in the modified intention-to-treat population (179 in the CTA group and 178 in the non-CTA group). The mean intraoperative blood loss (CTA vs non-CTA; 74.2 vs 95.0 mL, P = 0.005) and operation time (215.4 vs 231.2 min, P = 0.004) was significantly lower in the CTA group. Total number of retrieved lymph nodes was similar in two groups (32.2 vs 30.2, P = 0.070). The CTA group had a significantly lower surgery task load index sore than the non-CTA group (36.6 vs 41.7, P < 0.001). There was no significant difference in postoperative complications rate of 14.5% in the CTA group and 22.5% in the non-CTA group (difference, - 8.0% [95% CI, - 16.0 to 0.1]; P = 0.053).

CONCLUSION

Preoperative CTA associated with surgical decision-making could relieve surgery burden and lead to a better surgical performance compared with non-CTA support, which including decreased blood loss volume, vessel damage and operation time.

TRIAL REGISTRATION

NCT04636099.

Simulation training with haptic feedback of instrument vibrations reduces resident workload during live robot-assisted sleeve gastrectomy

BACKGROUND

New surgeons experience heavy workload during robot-assisted surgery partially because they must use vision to compensate for the lack of haptic feedback. We hypothesize that providing realistic haptic feedback during dry-lab simulation training may accelerate learning and reduce workload during subsequent surgery on patients.

METHODS

We conducted a single-blinded study with 12 general surgery residents (third and seventh post-graduate year, PGY) randomized into haptic and control groups. Participants performed five simulated bariatric surgeries on a custom inanimate simulator followed by live robot-assisted sleeve gastrectomies (RASGs) using da Vinci robots. The haptic group received naturalistic haptic feedback of instrument vibrations during their first four simulated procedures. Participants completed pre-/post-procedure STAI and post-procedure NASA-TLX questionnaires in both simulation and the operating room (OR).

RESULTS

Higher PGY level (simulation: p < 0.001, OR p = 0.004), shorter operative time (simulation: p < 0.001, OR p = 0.003), and lower pre-procedure STAI (simulation: p = 0.003, OR p < 0.001) were significantly associated with lower self-reported overall workload in both operative settings; PGY-7 s reported about 10% lower workload than PGY-3 s. The haptic group had significantly lower overall covariate-adjusted NASA-TLX during the fourth (p = 0.03) and fifth (p = 0.04) simulated procedures and across all OR procedures (p = 0.047), though not for only the first three OR procedures. Haptic feedback reduced physical demand (simulation: p < 0.001, OR p = 0.001) and increased perceived performance (simulation: p = 0.031, OR p < 0.001) in both settings.

CONCLUSION

Haptic feedback of instrument vibrations provided during robotic surgical simulation reduces trainee workload during both simulation and live OR cases. The implications of workload reduction and its potential effects on patient safety warrant further investigation.

The Use of Augmented Reality as an Educational Tool in Minimally Invasive Transforaminal Lumbar Interbody Fusion

BACKGROUND AND OBJECTIVES

One of the major challenges in training neurosurgical and orthopedic residents the technique for minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is the lack of visualization of surgical landmarks (pedicle, pars, lamina). This is due to the limited access to the bony spine through a tubular retractor, in addition to a smaller working corridor or patient-specific factors such as bony overgrowth, disk space collapse, and listhesis. These factors increase the possibility for surgical error and prolonged surgery time. With augmented reality (AR), relevant surgical anatomy can be projected directly into the user's field of view through the microscope. The purpose of this study was to assess the utility, accuracy, efficiency, and precision of AR-guided MIS-TLIF and to determine its impact in spine surgery training.

METHODS

At 2 centers, 12 neurosurgical residents performed a one-level MIS-TLIF on a high-fidelity lumbar spine simulation model with and without AR projection into the microscope. For the MIS-TLIF procedures with AR, surgical landmarks were highlighted in different colors on preoperative image data . These landmarks were visualized in the spinal navigation application on the navigation monitor and in the microscope to confirm the relevant anatomy. Postprocedural surveys (National Aeronautics and Space Administration Task Load Index) were given to the residents.

RESULTS

Twelve residents were included in this trial. AR-guided procedures had a consistent impact on resident anatomical orientation and workload experience. Procedures performed without AR had a significantly higher mental demand ( P = .003 ) than with AR. Residents reported to a significantly higher rate that it was harder work for them to accomplish their level of performance without AR ( P = .019 ).

CONCLUSION

AR can bring a meaningful value in MIS teaching and training to confirm relevant anatomy in situations where the surgeon will have less direct visual access. AR used in surgical simulation can also speed the learning curve.

Ambiguity in robotic surgical instruction: lessons from remote and in-person simulation

The rise of robotic surgery has been accompanied by numerous educational challenges as surgeons and trainees learn skills unique to the robotic platform. Remote instruction is a solution to provide surgeons ongoing education when in-person teaching is not feasible. However, surgical instruction faces challenges from unclear communication. We aimed to describe, examine, and compare ambiguities in remote and in-person robotic instruction. We designed a simulation scenario in which a standardized learner performed tasks in robotic surgery while making pre-scripted errors. Instructors provided remote or in-person instruction to the standardized learner. We applied tools from discourse analysis to transcribe sessions, identify instructional instances, classify ambiguities, and select passages for further review. We used tests of proportions to compare ambiguities between the settings. We conducted four simulation sessions, including two remote and two in-person sessions, and identified 206 instructional instances. Within these, we found 964 occurrences of three common semantic ambiguities, or ambiguities arising from words alone. Instructors used visual tools - thus employing multimodality - to clarify semantic ambiguities in 32% of instructional instances. We identified a similar degree of referential ambiguity, or ambiguity for which context from multimodality did not provide clarifying information, during remote (60%) and in-person (48%) instructional instances (p = 0.08). We described, examined, and compared ambiguities in remote and in-person instruction for simulated robotic surgery. Based on the high prevalence of ambiguity in both settings, we recommend that robotic instructors decrease referential ambiguity. To do so, instructors can reduce semantic ambiguity, harness multimodality, or both.

A Mixed Reality-Based Telesupervised Ultrasound Education Platform on 5G Network Compared to Direct Supervision: Prospective Randomized Pilot Trial

Background

Ultrasound education is transitioning from in-person training to remote methods using mixed reality (MR) and 5G networks. Previous studies are mainly experimental, lacking randomized controlled trials in direct training scenarios.

Objective

This study aimed to compare an MR-based telesupervised ultrasound education platform on private 5G networks with traditional in-person training for novice doctors.

Methods

Conducted at a tertiary academic hospital from November to December 2023, the prospective unblinded randomized controlled pilot study assigned doctors without prior abdominal ultrasound education experience to either the telesupervision group (TG; n=20) or direct supervision group (DG; n=20). Participants received a 15-minute video lecture, conducted ultrasound on a phantom, and had 18 images scored by 2 blinded experts. Additionally, the TG received 5 minutes of training on the basic operation of a head-mounted display. Communication between doctors in the TG and supervisors was facilitated through a head-mounted display, whereas those in the DG interacted directly with supervisors. Primary outcomes were image quality scores, while secondary outcomes included procedure time, number of supervisor interventions, user experience using National Aeronautics and Space Administration-Task Load Index (NASA-TLX), System Usability Scale (SUS), and self-confidence through pre- and postsurveys.

Results

Image quality scores and procedure times showed no significant differences between the groups (TG: 66.8 [SD 10.3] vs DG: 66.8 [SD 10.4], P=.84; TG: 23.8 [SD 8.0] min vs DG: 24.0 [SD 8.1] min, P=.95, respectively). However, the TG engaged in more educational interventions (TG: 4.0 [SD 2.5] vs DG: 0.8 [SD 1.1], P<.001), reflecting a more interactive training environment. TG participants reported lower NASA-TLX scores for mental demand (43.8 [SD 24.8] vs 60.6 [SD 22.4], P=.03), effort (43.1 [SD 22.9] vs 67.9 [SD 17], P<.001), and frustration (26.9 [SD 20.3] vs 45.2 [SD 27.8], P=.02), indicating a reduced cognitive load compared to the DG. The mean SUS score was also higher in the TG (66.6 [SD 9.1] vs 60.2 [SD 10.4], P=.046), suggesting better usability. Both groups showed significant improvements in confidence, with the TG showing notably greater improvement in abdominal ultrasound proficiency (pre-education TG: 1.6 [SD 0.9] vs DG: 1.7 [SD 0.9], P=.73; post-education TG: 3.8 [SD 0.9] vs DG: 2.8 [SD 1.0], P=.006).

Conclusions

Although no significant differences in image quality scores were observed between groups, considerable differences in positive educational interactions, workload, and usability were evident. These findings emphasize the platform's potential to enhance the ultrasound training experience, suggesting more interactive and efficient learning.

Factors prolonging the operative time for transumbilical laparoscopic-assisted appendectomy in pediatric patients: a retrospective single-center study

PURPOSE

Transumbilical laparoscopic-assisted appendectomy (TULAA) is one of the first endoscopic surgeries performed by trainee pediatric surgeons. While the operative time is generally shorter than for conventional laparoscopic appendectomy, the indications for this procedure are unclear and many unknown factors can prolong the operative time. We conducted this study to identify the factors that may prolong the operative time for TULAA.

METHODS

This retrospective, single-center study was conducted between 2015 and 2023. We performed multivariate analysis to identify the factors associated with prolonged operative time by analyzing TULAA procedures performed by trainees.

RESULTS

The study included 243 patients. The median operative time was 84 min (interquartile range, 69-114 min). Multivariate analysis revealed that an increased body mass index, elevated C-reactive protein level, a history of conservative treatment for acute appendicitis, and appendix perforation, for the patient; < 6 years' experience since graduation for the operating surgeon; and lack of board certification as a supervisor from the Japanese Society of Pediatric Surgeons for the attending surgeon were independent risk factors for prolonging the operative time.

CONCLUSION

Having an attending surgeon with board certification as a supervisor by the Japanese Society of Pediatric Surgeons contributes to reducing the operative time required for TULAA.

A multi-institutional feasibility lead-in trial of lymphatic mapping with SPECT-CT for evaluating contralateral disease in lateralized oropharynx cancer using 99m-technetium sulfur colloid

BACKGROUND

Lymphatic mapping with SPECT-CT has been demonstrated to accurately define lymphatic drainage patterns in oropharyngeal cancer but there has yet to be a study demonstrating its feasibility across multiple institutions.

METHODS

Twelve adult patients with lateralized oropharyngeal carcinoma (T1-T3) who were planned for definitive or adjuvant radiotherapy without contralateral nodal disease underwent injection of 99-m technetium sulfur colloid followed by static planar lymphoscintigraphy to verify tracer migration, and SPECT-CT acquired at 30 ± 15 min (optional) and 3 h (±1 h) (mandatory time-point).

RESULTS

All 12 patients completed the study with 7/12 patients having the injections performed under local anesthetic and 5 patients requiring general anesthetic. There were no tracer migration failures and there were no serious adverse events or complications encountered. Four out of 12 patients (33%) showed contralateral drainage patterns.

CONCLUSIONS

Lymphatic mapping with SPECT-CT of lateralized oropharyngeal squamous cell carcinoma can be performed safely across multiple institutions.

Estimating Cognitive Workload Using Task-Related Pupillary Responses in Simulated Drilling in Cochlear Implantation

OBJECTIVES

Training of temporal bone drilling requires more than mastering technical skills with the drill. Skills such as visual imagery, bimanual dexterity, and stress management need to be mastered along with precise knowledge of anatomy. In otorhinolaryngology, these psychomotor skills underlie performance in the drilling of the temporal bone for access to the inner ear in cochlear implant surgery. However, little is known about how psychomotor skills and workload management impact the practitioners' continuous and overall performance.

METHODS

To understand how the practitioner's workload and performance unfolds over time, we examine task-evoked pupillary responses (TEPR) of 22 medical students who performed transmastoid-posterior tympanotomy (TMPT) and removal of the bony overhang of the round window niche in a 3D-printed model of the temporal bone. We investigate how students' TEPR metrics (Average Pupil Size [APS], Index of Pupil Activity [IPA], and Low/High Index of Pupillary Activity [LHIPA]) and time spent in drilling phases correspond to the performance in key drilling phases.

RESULTS

All TEPR measures revealed significant differences between key drilling phases that corresponded to the anticipated workload. Enlarging the facial recess lasted significantly longer than other phases. IPA captured significant increase of workload in thinning of the posterior canal wall, while APS revealed increased workload during the drilling of the bony overhang.

CONCLUSION

Our findings contribute to the contemporary competency-based medical residency programs where objective and continuous monitoring of participants' progress allows to track progress in expertise acquisition. Laryngoscope, 134:5087-5095, 2024.

Safety and efficacy of the MP1000 surgical system in robot-assisted radical cystectomy: A prospective study

Background

Robot-assisted radical cystectomy (RARC) has become widely adopted due to its numerous advantages, with the da Vinci robotic surgical system being the most commonly used across the globe. However, the high cost limits its broader application.

Objective

This study aimed to evaluate the safety and efficacy of performing RARC using the more economical MP1000 surgical system.

Methods

In this prospective, single-center, single-blind study, 21 patients scheduled for RARC between April and June 2024 were randomly assigned to undergo surgery with either the da Vinci Si system or the MP1000 system. The primary outcome was the rate of conversion to open or laparoscopic surgery. Secondary outcomes included robotic arm installation time, total surgery duration, intraoperative complications, intraoperative blood loss, post-operative positive margin rate, length of post-operative hospital stay, and short-term post-operative complications.

Results

All surgeries were successfully completed without conversion to open or laparoscopic procedures, and no intraoperative complications related to robotic mechanical failure were observed. The robotic arm installation time was slightly longer with the MP1000 system compared to the da Vinci Si system (20.75 vs. 17.13 min, P < 0.001). There were no statistically significant differences between the two groups in surgery duration, intraoperative blood loss, post-operative positive margin rate, post-operative hospital stay, or short-term post-operative complications. In addition, there was no significant difference in National Aeronautics and Space Administration Task Load Index scores, a measure of the operator workload. The primary limitation of this study was its small sample size.

Conclusion

The study demonstrated that the MP1000 surgical system was a safe, feasible, and effective alternative for RARC, and achieved comparable outcomes to the da Vinci Si system.

Use of eye tracking in medical education

Eye tracking has become increasingly applied in medical education research for studying the cognitive processes that occur during the performance of a task, such as image interpretation and surgical skills development. However, analysis and interpretation of the large amount of data obtained by eye tracking can be confusing. In this article, our intention is to clarify the analysis and interpretation of the data obtained from eye tracking. Understanding the relationship between eye tracking metrics (such as gaze, pupil and blink rate) and cognitive processes (such as visual attention, perception, memory and cognitive workload) is essential. The importance of calibration and how the limitations of eye tracking can be overcome is also highlighted.

Factors contributing to prolonged operative time for laparoscopic cholecystectomy performed by trainee surgeons: a retrospective single-center study

PURPOSE

Laparoscopic cholecystectomy for a benign disease is often the initial endoscopic surgery performed by trainee surgeons. However, a lack of surgical experience is associated with prolonged operative times, which may increase the risk of postoperative complications and poor outcomes. This study aimed to identify the factors associated with prolonged operative times for laparoscopic cholecystectomy performed by inexperienced surgeons.

METHODS

This retrospective single-center study was conducted between January 2018 and December 2023. We performed a multivariate analysis to identify the factors associated with prolonged operative time by analyzing elective cases of laparoscopic cholecystectomy performed by surgeons with limited experience.

RESULTS

The study included 323 patients, subjected to a median operative time of 89 min. Multivariate analysis identified that patient characteristics such as male sex, increased body mass index, and a history of conservative treatment for cholecystitis, as well as operating surgeon's post-graduation years (< 4 years), and an attending surgeon without endoscopic surgical skill certification from the Japan Society of Endoscopic Surgery, were independent risk factors for a prolonged operative time.

CONCLUSION

Our findings suggest that endoscopic surgical skill-certified attending surgeons have excellent coaching skills and mitigate the operative time for elective cholecystectomy.

Assessing and evaluating the impact of operative vision compromise (OViC) on surgeons' practice: a qualitative study

BACKGROUND

Assessing the effects of compromised vision in laparoscopic and robotic procedures is crucial to understanding its impact on surgical practice and patient safety. Our aim was to examine the impact of operative vision compromise (OViC) on surgeons' practice.

METHODS

Intraoperative workload was qualitatively assessed using the NASA-TLX score. Participants included internationally trained surgeons performing laparoscopic sleeve gastrectomy (LSG) procedures. Video recordings of LSG procedures were quantitatively analyzed to assess OViC event frequency and duration to determine their influence on procedural time and surgical flow in a secondary care center. Surgeons' views on OViC were assessed using a custom survey. Cost analysis of basic expenditures was performed.

RESULTS

Among 109 participants, the overall NASA-TLX score for OViC was 71.7, indicating a high workload. Out of 81 LSG procedures, 77 experienced at least one lens fouling episode, resulting in 471 OViC events, including 371 lens cleaning occurrences. Significant positive correlations were found between total procedure time and several OViC variables. Compromised vision accounted for 19.3% of total operative time. Lens cleaning constituted 2.5% of the total operative time. In nine (11%) cases, lens cleaning added an average of 7 min per procedure, with the most severe case adding 15 min of operative time. The majority of surgeons (94%) found OViC to impair their performance and compromise patient safety, with 61% reporting witnessing surgical errors or complications directly attributable to OViC.

CONCLUSIONS

OViC was linked to increased procedure time, surgical flow disruptions, elevated surgeon workload, cognitive burden, and frustration, and potential patient safety concerns. These findings emphasize the need for innovative solutions to mitigate OViC, thereby potentially minimizing errors and enhancing operative outcomes.

Feasibility of Wearable Sensors to Assess Cognitive Load During Clinical Performance: Lessons Learned and Blueprint for Success

INTRODUCTION

Cognitive load (CogL) is increasingly recognized as an important resource underlying operative performance. Current innovations in surgery aim to develop objective performance metrics via physiological monitoring from wearable digital sensors. Surgeons have access to consumer technology that could measure CogL but need guidance regarding device selection and implementation. To realize the benefits of surgical performance improvement these methods must be feasible, incorporating human factors usability and design principles. This paper aims to evaluate the feasibility of using wearable sensors to assess CogL, identify the benefits and challenges of implementing devices, and develop guidance for surgeons planning to implement wearable devices in their research or practice.

METHODS

We examined the feasibility of wearable sensors from a series of empirical studies that measured aspects of clinical performance relating to CogL. Across four studies, 84 participants and five sensors were involved in the following clinical settings: (i) real intraoperative surgery; (ii) simulated laparoscopic surgery; and (iii) medical team performance outside the hospital.

RESULTS

Wearable devices worn on the wrist and chest were found to be comfortable. After a learning curve, electrodermal activity data were easily and reliably collected. Devices using photoplethysmography to determine heart rate variability were significantly limited by movement artifact. There was variable success with electroencephalography devices regarding connectivity, comfort, and usability.

CONCLUSIONS

It is feasible to use wearable sensors across various clinical settings, including surgery. There are some limitations, and their implementation is context and device dependent. To scale sensor use in clinical research, surgeons must embrace human factors principles to optimize wearability, usability, reliability, and data security.

Mental workload evaluation using weighted phase lag index and coherence features extracted from EEG data

Electroencephalogram (EEG) represents an effective, non-invasive technology to study mental workload. However, volume conduction, a common EEG artifact, influences functional connectivity analysis of EEG data. EEG coherence has been used traditionally to investigate functional connectivity between brain areas associated with mental workload, while weighted Phase Lag Index (wPLI) is a measure that improves on coherence by reducing susceptibility to volume conduction, a common EEG artifact. The goal of this study was to compare two methods of functional connectivity analysis, wPLI and coherence, in the context of mental workload evaluation. The study involved model development for mental workload domains and comparing their performance using coherence-based features, wPLI-based features, and a combination of both. Generalized linear mixed-effects model (GLMM) with the least absolute shrinkage and selection operator (LASSO) feature selection method was used for model development. Results indicated that the model developed using a combination of both feature types demonstrated improved predictive performance across all mental workload domains, compared to models that used each feature type individually. The R2 values were 0.82 for perceived task complexity, 0.71 for distraction, 0.91 for mental demand, 0.85 for physical demand, 0.74 for situational stress, and 0.74 for temporal demand. Furthermore, task complexity and functional connectivity patterns in different brain areas were identified as significant contributors to perceived mental workload (p-value<0.05). Findings showed the potential of using EEG data for mental workload evaluation which suggests that combination of coherence and wPLI can improve the accuracy of mental workload domains prediction. Future research should aim to validate these results on larger, diverse datasets to confirm their generalizability and refine the predictive models.

Quantifying the effects of training in lung transplantation: Lessons from NASA

Background

Sequential lung transplantation is a complex procedure. The traditional training model continues to center around operative experience with progressively increasing delegation of stages of the procedure. However, little evidence exists on the effects this has on surgical trainers. The NASA-TLX is a subjective, multidimensional assessment tool that rates perceived workload. We sought to employ this as a means of assessing the impact that training in lung transplantation has on trainers.

Methods

We prospectively collected the NASA-TLX data for 60 patients undergoing bilateral sequential lung transplantation. In 30 cases, the operation was performed entirely by the senior surgeon (SS) who implanted both lungs. In 30 operations, the senior surgeon implanted the right lung (SSR) and supervised a trainee implanting the left lung (TL).

Results

The overall weighted rating was significantly lower for the surgeons undertaking the case themselves rather than training (p < 0.001). Cases were comparable in terms of case type, donor ischemic time, and peri-operative characteristics. Mental and temporal demands were greater throughout training cases (p < 0.001, p < 0.05). There was less effect on frustration, physical demand, and effort. Perceived performance showed no significant difference between the groups.

Conclusions

The NASA task load index can be used to inform the effects of training in lung transplantation on trainers. Training leads to greater mental and temporal demands with less effect on other factors. Crucially, there was no significant difference in perceived performance. As the specialty continues to be confronted with diverse challenges, this study should give confidence to those training the transplant surgeons of the future, as well as provide them with a mechanism to reflect on their own training performance.

ACGME Competencies

Interpersonal and communication skills.Practice-based learning and improvement.

A novel multimodal, intraoperative cognitive workload assessment of cardiac surgery team members

OBJECTIVE

To characterize cognitive workload (CWL) of cardiac surgery team members in a real-world setting during coronary artery bypass grafting (CABG) surgery using providers' heart rate variability (HRV) data as a surrogate measure of CWL.

METHODS

HRV was collected from the surgeon, anesthesiologist, perfusionist, and scrub nurse, and audio/video recordings were made during isolated, nonemergency CABG surgeries (n = 27). Eight surgical phases were annotated by trained researchers, and HRV was calculated for each phase.

RESULTS

Significant differences in CWL were observed within a given role across surgical phases. Results are reported as predicted probability (95% confidence interval [CI]). CWL was significantly higher for anesthesiologists during "preparation and induction" (0.57; 95% CI, 0.42-0.71) and "anastomoses" (0.44; 95% CI, 0.30-0.58) compared to other phases, and the same held for nurses during the "opening" (0.51; 95% CI, 0.37-0.65) and "postoperative" (0.68; 95% CI, 0.42-0.86) phases. Additional significant differences were observed between roles within a given surgical phase. For example, surgeons had significantly higher CWL during "anastomoses" (0.81; 95% CI, 0.69-0.89) compared to all other phases, and the same was true of perfusionists during the "opening" (0.79; 95% CI, 0.66-0.88) and "prebypass preparation" (0.50; 95% CI, 0.36-0.64) phases.

CONCLUSIONS

Our innovative analysis demonstrates that CWL fluctuates across surgical procedures by role and phase, which may reflect the distribution of primary tasks. This corroborates earlier findings from self-report measures. The data suggest that team-wide, peak CWL during a phase decreases from early phases of surgery through initiation of cardiopumonary bypass (CPB), rises during anastomosis, and decreases after termination of CPB. Knowledge of these trends could encourage the adoption of behaviors to enhance team dynamics and performance.

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.

Revision Total Joint Arthroplasty Places a Disproportionate Burden on Surgeons: A Comparison Using the National Aeronautics and Space Administration Task Load Index (NASA TLX)

BACKGROUND

Perceived surgeon workload of performing primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) is challenging to quantify. The National Aeronautics and Space Administration Task Load Index (NASA TLX) survey was developed to quantify experiences following aviation and has been applied to healthcare fields. Our purposes were to 1) quantify the workload endured by surgeons who are performing primary and revision TKA and THA and 2) compare these values to their Center for Medicare & Medicaid Services (CMS) reimbursement.

METHODS

A prospective cohort of 5 fellowship-trained adult reconstruction surgeons completed NASA TLX surveys following primary and revision TKA/THA cases. A total of 122 surveys consisting of 70 TKA (48 primaries and 22 revisions) and 55 THA surveys (38 primaries and 17 revisions) were completed. Patient demographics and surgical variables were recorded. Final NASA TLX workloads were compared to 2021 CMS work relative value units.

RESULTS

Compared to primary TKA, revision TKA had 176% increased intraoperative workload (P < .001), 233% increased mental burden (P < .001), and 150% increased physical burden (P < .001). Compared to primary THA, revision THA had 106% increased intraoperative workload (P < .001), 96% increased mental burden (P < .001), and 91% increased physical burden (P < .001). Operative time was higher in revision versus primary TKA (118 versus 84.5 minutes, P = .05) and THA (150 versus 115 minutes, P = .001). Based upon 2021 CMS data, revision TKA and THA would need to be compensated by an additional 36% and 12.3%, respectively, to parallel intraoperative efforts.

CONCLUSIONS

Revision hip and knee arthroplasty places a major mental and physical workload upon surgeons and is disproportionately compensated by CMS.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pupil Response in Visual Tracking Tasks: The Impacts of Task Load, Familiarity, and Gaze Position

Pupil size is a significant biosignal for human behavior monitoring and can reveal much underlying information. This study explored the effects of task load, task familiarity, and gaze position on pupil response during learning a visual tracking task. We hypothesized that pupil size would increase with task load, up to a certain level before decreasing, decrease with task familiarity, and increase more when focusing on areas preceding the target than other areas. Fifteen participants were recruited for an arrow tracking learning task with incremental task load. Pupil size data were collected using a Tobii Pro Nano eye tracker. A 2 × 3 × 5 three-way factorial repeated measures ANOVA was conducted using R (version 4.2.1) to evaluate the main and interactive effects of key variables on adjusted pupil size. The association between individuals' cognitive load, assessed by NASA-TLX, and pupil size was further analyzed using a linear mixed-effect model. We found that task repetition resulted in a reduction in pupil size; however, this effect was found to diminish as the task load increased. The main effect of task load approached statistical significance, but different trends were observed in trial 1 and trial 2. No significant difference in pupil size was detected among the three gaze positions. The relationship between pupil size and cognitive load overall followed an inverted U curve. Our study showed how pupil size changes as a function of task load, task familiarity, and gaze scanning. This finding provides sensory evidence that could improve educational outcomes.

Operating under the influence: the effect of alcohol on operative performance using a virtual robotic training platform-an experimental comparative cohort study

An elevated percentage of medical personnel reports using alcohol to relieve stress. Levels of alcohol addiction are almost double that of the general population. Robotic surgery is becoming more widespread. The purpose of this study is to evaluate the effects of alcohol ingestion on performance of a standardized curriculum using a robotic training platform. Surgeons and surgical trainees were recruited. Candidates performed 4 standardized exercises (Vitruvian Operation (VO), Stacking Challenge (SC), Ring Tower (RT), Suture Sponge (SS)) at 0.0 blood alcohol concentration (BAC), followed by testing in the elimination phase at a target BAC of 0.8‰. Learning effects were minimised through prior training. A total of 20 participants were recruited. Scores for RT and SS exercises were significantly worse under the influence of alcohol [instruments out of view (SS (z = 2.012; p = 0.044), RT (z score 1.940, p = 0.049)), drops (SS (z = 3.250; p = 0.001)), instrument collisions (SS (z = 2.460; p = 0.014)), missed targets (SS (z = 2.907; p = 0.004)]. None of the scores improved with alcohol consumption, and there were measurable deleterious effects on the compound indicators risk affinity and tissue handling. Despite the potential mitigating features of robotic surgery including tremor filtration, motion scaling, and improved three-dimensional visualization, alcohol consumption was associated with a significant increase in risk affinity and rough tissue handling, along with a deterioration of performance in select virtual robotic tasks. In the interest of patient safety, alcohol should not be consumed prior to performing robotic surgery and sufficiently long intervals between alcohol ingestion and surgical performance are mandatory.

Cognitive ergonomics and robotic surgery

Cognitive ergonomics refer to mental resources and is associated with memory, sensory motor response, and perception. Cognitive workload (CWL) involves use of working memory (mental strain and effort) to complete a task. The three types of cognitive loads have been divided into intrinsic (dependent on complexity and expertise), extraneous (the presentation of tasks) and germane (the learning process) components. The effect of robotic surgery on CWL is complex because the postural, visualisation, and manipulation ergonomic benefits for the surgeon may be offset by the disadvantages associated with team separation and reduced situation awareness. Physical fatigue and workflow disruptions have a negative impact on CWL. Intraoperative CWL can be measured subjectively post hoc with the use of self-reported instruments or objectively with real-time physiological response metrics. Cognitive training can play a crucial role in the process of skill acquisition during the three stages of motor learning: from cognitive to integrative and then to autonomous. Mentorship, technical practice and watching videos are the most common traditional cognitive training methods in surgery. Cognitive training can also occur with computer-based cognitive simulation, mental rehearsal, and cognitive task analysis. Assessment of cognitive skills may offer a more effective way to differentiate robotic expertise level than automated performance (tool-based) metrics.

Comparison of cognitive workload and surgical outcomes between a three-dimensional and conventional microscope macular hole surgery

BACKGROUND

Performing a surgical task subjects the surgeon to multitudinal stressors, especially with the newer 3D technology. The quantum of cognitive workload using this modern surgical system in comparison to the Conventional microscope system remains unexplored. We evaluate the surgeon's cognitive workload and the surgical outcomes of macular hole(MH) surgery performed on a 3D versus a Conventional microscope operating system.

METHODS

50 eyes of 50 patients with MH undergoing surgery using the 3D or Conventional microscope visualization system. Cognitive workload assessment was done by real-time tools(Surgeons' heart rate [HR] and oxygen saturation[SPO2]) and self-report tool(Surgery Task Load Index[SURG-TLX] questionnaire) of three Vitreoretinal surgeons. Based on the SURG-TLX questionnaire, an assessment of the workload was performed.

RESULTS

Of the 50 eyes, 30 eyes and 20 eyes underwent surgery with the Conventional microscope and the 3D system, respectively. No difference was noted in the MH basal-diameter(p = 0.128), total surgical-duration(p = 0.299), internal-limiting membrane(ILM) peel time(p = 0.682), and the final visual acuity (VA; p = 0.515) between the two groups. Both groups showed significant improvement in VA(p < 0.001) with a 90% closure rate at one-month post-surgery. Cognitive workload comparison, the intraoperative HR(p = 0.024), total workload score(P = 0.005), and temporal-demand dimension(p = 0.004) were significantly more in Conventional microscope group as compared to 3D group. In both the groups, the HR increased significantly from the baseline while performing ILM peeling and at the end.

CONCLUSION

The surgeon's cognitive workload is markedly reduced while performing macular hole surgery with a 3D viewing system. Moreover, duration of surgery including ILM peel time, MH closure rates, and visual outcomes remains unaffected irrespective of the operating microscope system.

Granular estimation of user cognitive workload using multi-modal physiological sensors

Mental workload (MWL) is a crucial area of study due to its significant influence on task performance and potential for significant operator error. However, measuring MWL presents challenges, as it is a multi-dimensional construct. Previous research on MWL models has focused on differentiating between two to three levels. Nonetheless, tasks can vary widely in their complexity, and little is known about how subtle variations in task difficulty influence workload indicators. To address this, we conducted an experiment inducing MWL in up to 5 levels, hypothesizing that our multi-modal metrics would be able to distinguish between each MWL stage. We measured the induced workload using task performance, subjective assessment, and physiological metrics. Our simulated task was designed to induce diverse MWL degrees, including five different math and three different verbal tiers. Our findings indicate that all investigated metrics successfully differentiated between various MWL levels induced by different tiers of math problems. Notably, performance metrics emerged as the most effective assessment, being the only metric capable of distinguishing all the levels. Some limitations were observed in the granularity of subjective and physiological metrics. Specifically, the subjective overall mental workload couldn't distinguish lower levels of workload, while all physiological metrics could detect a shift from lower to higher levels, but did not distinguish between workload tiers at the higher or lower ends of the scale (e.g., between the easy and the easy-medium tiers). Despite these limitations, each pair of levels was effectively differentiated by one or more metrics. This suggests a promising avenue for future research, exploring the integration or combination of multiple metrics. The findings suggest that subtle differences in workload levels may be distinguishable using combinations of subjective and physiological metrics.

Collaborative robots can augment human cognition in regret-sensitive tasks

Despite theoretical benefits of collaborative robots, disappointing outcomes are well documented by clinical studies, spanning rehabilitation, prostheses, and surgery. Cognitive load theory provides a possible explanation for why humans in the real world are not realizing the benefits of collaborative robots: high cognitive loads may be impeding human performance. Measuring cognitive availability using an electrocardiogram, we ask 25 participants to complete a virtual-reality task alongside an invisible agent that determines optimal performance by iteratively updating the Bellman equation. Three robots assist by providing environmental information relevant to task performance. By enabling the robots to act more autonomously-managing more of their own behavior with fewer instructions from the human-here we show that robots can augment participants' cognitive availability and decision-making. The way in which robots describe and achieve their objective can improve the human's cognitive ability to reason about the task and contribute to human-robot collaboration outcomes. Augmenting human cognition provides a path to improve the efficacy of collaborative robots. By demonstrating how robots can improve human cognition, this work paves the way for improving the cognitive capabilities of first responders, manufacturing workers, surgeons, and other future users of collaborative autonomy systems.

Ergonomics in Urology: Current Landscape and Future Directions

Optimal ergonomics are essential to improving clinical performance and longevity among urologists, as poor ergonomics can contribute to work-related injury and physician burnout. While a majority of urologists experience muscular injury throughout their career, women and trainees are disproportionately affected. These disparities are exacerbated by the lack of formal ergonomics education within urologic training programs. This review provides an overview of practical approaches to optimize ergonomics across working environments for urologists and trainees. We highlight intraoperative techniques and novel devices which have been shown to reduce work-related injury, and we identify knowledge gaps to guide future areas of ergonomic research.

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.

Simulated skill complexity and perceived cognitive load during preclinical dental training

INTRODUCTION

Cognitive Load theory (CLT) focuses on the information processing aspect of learning and how the working memory handles the mental effort associated with new task. The aim of this study is to investigate the association between the perceived cognitive load and performance amongst dental students during preclinical simulation training at various levels of procedural task complexity. Additionally, some cognitive load-modifying factors were examined.

MATERIALS AND METHODS

This cross-sectional study evaluated the perceived cognitive load amongst second-year dental students (n = 34), using the validated National Aeronautics and Space Administration's Task Load Index (NASA TLX index) after training on four dental tasks at two levels of complexity, in addition to structured online anonymous questionnaire about demographics, feedback and performance. The NASA TLX raw scores and the weighted global score were calculated for each exercise. Descriptive statistics and Pearson's correlations between performance and the corresponding NASA TLX-weighted score were calculated. Mean differences in the perceived cognitive load across the exercise levels were assessed using RM-ANOVA with Bonferroni corrections at p < .05.

RESULTS

Reduced performance was significantly associated with higher cognitive load particularly in high complexity dental task (class II-mirror vision). Simulated exercise complexity significantly influenced the students' perceived mental demand, physical demand and temporal demand; all were significantly higher for class II- mirror vision task than for direct vision tasks. The majority of participants (82.1%) preferred detailed feedback from instructors, and more than half of the participants (60.7%) preferred continuous feedback throughout the training session.

CONCLUSION

Complex dental tasks are associated with higher cognitive load in novice dental students during preclinical training. The NASA TLX index is a useful instrument to explore the level of perceived cognitive load associated with performance of simulated complex dental skills. Cognitive load theory is relevant to simulation-based dental education to improve the preclinical instructional efficiency and to enhance students learning.

Spinal Navigation for Lateral Instrumentation of the Thoracolumbar Spine

BACKGROUND AND OBJECTIVES

Three-dimensional imaging-based navigation in spine surgery is mostly applied for pedicle screw placement. However, its potential reaches beyond. In this study, we analyzed the incorporation of spinal navigation for lateral instrumentation of the thoracolumbar spine in clinical routine at a high-volume spine center.

METHODS

Patients scheduled for lateral instrumentation were prospectively enrolled. A reference array was attached to the pelvis, and a computed tomography scan was acquired intraoperatively. A control computed tomography scan was routinely performed after final cage placement, replacing conventional 2-dimensional X-ray imaging.

RESULTS

145 cases were enrolled from April to October 2021 with a median of 1 (1-4) level being instrumented. Indications for surgery were trauma (35.9%), spinal infection (31.7%), primary and secondary tumors of the spine (17.2%), and degenerative spine disease (15.2%). The duration of surgery after the first scan was 98 ± 41 (20-342) minutes. In total, 190 cages were implanted (94 expandable cages for vertebral body replacement (49.5%) and 96 cages for interbody fusion [50.5%]). Navigation was successfully performed in 139 cases (95.9%). The intraoperative mental load was rated on a scale from 0 to 150 (maximal effort) by the surgeons, showing a moderate effort (median 30 [10-120]).

CONCLUSION

Three-dimensional imaging-based spinal navigation can easily be incorporated in clinical routine and serves as a reliable tool to achieve precise implant placement in lateral instrumentation of the spine. It helps to minimize radiation exposure to the surgical staff.

Demands of surgical teams in robotic-assisted surgery: An assessment of intraoperative workload within different surgical specialties

BACKGROUND

Current approaches to assessing workload in robotic-assisted surgery (RAS) focus on surgeons and lack real-world data. Understanding how workload varies by role and specialty aids in identifying effective ways to optimize workload.

METHODS

SURG-TLX surveys with six domains of workload were administered to surgical staff at three sites. Staff reported workload perceptions for each domain on a 20-point Likert scale, and aggregate scores were determined per participant.

RESULTS

188 questionnaires were obtained across 90 RAS procedures. Significantly higher aggregate scores were reported for gynecology (Mdn ​= ​30.00) (p ​= ​0.034) and urology (Mdn ​= ​36.50) (p ​= ​0.006) than for general (Mdn ​= ​25.00). Surgeons reported significantly higher scores for task complexity (Mdn ​= ​8.00) than both technicians (Mdn ​= ​5.00) (p ​= ​0.007), and nurses (Mdn ​= ​5.00).

CONCLUSIONS

Staff reported significantly higher workload during urology and gynecology procedures, and experienced significant differences in domain workload by role and specialty, elucidating the need for tailored workload interventions.

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.

Crew Autonomy During Simulated Medical Event Management on Long Duration Space Exploration Missions

OBJECTIVE

Our primary aim was to investigate crew performance during medical emergencies with and without ground-support from a flight surgeon located at mission control.

BACKGROUND

There are gaps in knowledge regarding the potential for unanticipated in-flight medical events to affect crew health and capacity, and potentially compromise mission success. Additionally, ground support may be impaired or periodically absent during long duration missions.

METHOD

We reviewed video recordings of 16 three-person flight crews each managing four unique medical events in a fully immersive spacecraft simulator. Crews were randomized to two conditions: with and without telemedical flight surgeon (FS) support. We assessed differences in technical performance, behavioral skills, and cognitive load between groups.

RESULTS

Crews with FS support performed better clinically, were rated higher on technical skills, and completed more clinical tasks from the medical checklists than crews without FS support. Crews with FS support also had better behavioral/non-technical skills (information exchange) and reported significantly lower cognitive demand during the medical event scenarios on the NASA-TLX scale, particularly in mental demand and temporal demand. There was no significant difference between groups in time to treat or in objective measures of cognitive demand derived from heart rate variability and electroencephalography.

CONCLUSION

Medical checklists are necessary but not sufficient to support high levels of autonomous crew performance in the absence of real-time flight surgeon support.

APPLICATION

Potential applications of this research include developing ground-based and in-flight training countermeasures; informing policy regarding autonomous spaceflight, and design of autonomous clinical decision support systems.

Human Factors Approach to Assess Physician Workload in Elective Plastic Surgery Breast Procedures

Background

Human factors research involves the study of work system interactions, physician workload, cognitive effort, and performance. This pilot study incorporated a human factor approach and other surgery-based metrics to assess cognitive workload among plastic surgeons during elective plastic surgery breast procedures.

Methods

In this prospective study of plastic surgery breast procedures over a 3-month period, surgeon and patient demographics and procedural details were collected. The lead surgeon assessed each procedure using a validated workload questionnaire (National Aeronautics and Space Administration Task Load Index [NASA-TLX]) that included 6 subscales (ie, mental, physical, temporal demand, performance, effort, and frustration), a question on distraction, and their expectation of procedural difficulty.

Results

Fifty-seven cases were included in this study. Surgical duration had a positive correlation with increased mental demand (P < .001), physical demand (P < .001), and degree of distractions (P < .001). Free flap reconstruction, breast reduction, and transgender mastectomy had the highest average mental, physical demands, and perceived effort. Bilateral cases had significantly higher workload than unilateral ones (P = .002). NASA-TLX scores between immediate and delayed reconstructions were comparable, but delayed cases had higher degree of distractions (P = .04). There was a strong correlation between degree of distractions and increased mental workload (R = 0.68; P < .001), increased physical demand (P = 0.61; P < .001), and increased temporal demand (R = 0.78; P < .001). More difficult procedures were associated with greater procedural duration than those rated as difficult as expected or less difficult than expected (P = .02).

Conclusions

These preliminary data demonstrated multiple factors that may influence and govern perceived physician workload and may provide insight for targeted quality improvement to plan procedures safely and effectively.

Identifying the response process validity of clinical vignette-type multiple choice questions: An eye-tracking study

INTRODUCTION

Clinical vignette-type multiple choice questions (CV-MCQs) are widely used in assessment and identifying the response process validity (RPV) of questions with low and high integration of knowledge is essential. Answering CV-MCQs of different levels of knowledge application and integration can be understood from a cognitive workload perspective and this can be identified by using eye-tracking. The aim of the pilot study was to identify the cognitive workload and RPV of CV-MCQs of different levels of knowledge application and integration by the use eye-tracking.

METHODS

Fourteen fourth-year medical students answered a test with 40 CV-MCQs, which were equally divided into low-level and high-level complexity (knowledge application and integration). Cognitive workload was measured using screen-based eye tracking, with the number of fixations and revisitations for each area of interest.

RESULTS

We found a higher cognitive workload for high-level complexity (M = 121.74) compared with lower-level complexity questions (M = 51.94) and also for participants who answered questions incorrectly (M = 94.31) compared with correctly (M = 79.36).

CONCLUSION

Eye-tracking has the potential to become a useful and practical approach for helping to identify the RPV of CV-MCQs. This approach can be used for improving the design and development of CV-MCQs, and to provide feedback to inform teaching and learning.[Box: see text].

Emerging Applications for Computer Vision and Artificial Intelligence in Management of the Cardiovascular Patient

Artificial intelligence and telemedicine promise to reshape patient care to an unprecedented extent, leading to a safer and more sustainable work environment and improved patient care. In this article, we summarize how these emerging technologies can be used in the care of cardiovascular patients in such ways as fall detection and prevention, virtual nursing, remote case support, automation of instrument counts in the operating room, and efficiency optimization in the cardiovascular suite.

Cognitive Ergonomics: A Review of Interventions for Outpatient Practice

Doctoring is difficult mental work, involving many cognitively demanding processes such as diagnosing, decision-making, parallel processing, communicating, and managing the emotions of others. According to cognitive load theory (CLT), working memory is a limited cognitive resource that can support a finite amount of cognitive load. While the intrinsic cognitive load is the innate load associated with a task, the extraneous load is generated by inefficiency or suboptimal work conditions. Causes of extraneous cognitive load in healthcare include inefficiency, distractions, interruptions, multitasking, stress, poor communication, conflict, and incivility. High levels of cognitive load are associated with impaired function and an increased risk of burnout among physicians. Cognitive ergonomics is the branch of human factors and ergonomics (HFE) focused on supporting the cognitive processes of individuals within a system. In health care, where the cognitive burden on physicians is high, cognitive ergonomics can establish practices and systems that decrease extraneous cognitive load and support pertinent cognitive processes. In this review, we present cognitive ergonomics as a useful framework for conceptualizing an oft-overlooked dimension of labor and apply theory to practice by summarizing evidence-based cognitive ergonomics interventions for outpatient care settings. Our proposed interventions are structured within four general recommendations: 1. minimize distractions, interruptions, and multitasking; 2. optimize the use of the electronic health record (EHR); 3. optimize the use of health information systems (HIS); and 4. support good communication and teamwork. Best practices in cognitive ergonomics can benefit patients, minimize practice inefficiency, and support physician career longevity.

Robotic-assisted versus laparoscopic bowel anastomoses: randomized crossover in vivo experimental study

BACKGROUND

Initial learning curves are potentially shorter in robotic-assisted surgery (RAS) than in conventional laparoscopic surgery (LS). There is little evidence to support this claim. Furthermore, there is limited evidence how skills from LS transfer to RAS.

METHODS

A randomized controlled, assessor blinded crossover study to compare how RAS naïve surgeons (n = 40) performed linear-stapled side-to-side bowel anastomoses in an in vivo porcine model with LS and RAS. Technique was rated using the validated anastomosis objective structured assessment of skills (A-OSATS) score and the conventional OSATS score. Skill transfer from LS to RAS was measured by comparing the RAS performance of LS novices and LS experienced surgeons. Mental and physical workload was measured with the NASA-task load index (NASA-Tlx) and the Borg-scale.

OUTCOMES

In the overall cohort, there were no differences between RAS and LS for surgical performance (A-OSATS, time, OSATS). Surgeons that were naïve in both LS and RAS had significantly higher A-OSATS scores in RAS (Mean (Standard deviation (SD)): LS: 48.0 ± 12.1; RAS: 52.0 ± 7.5); p = 0.044) mainly deriving from better bowel positioning (LS: 8.7 ± 1.4; RAS: 9.3 ± 1.0; p = 0.045) and closure of enterotomy (LS: 12.8 ± 5.5; RAS: 15.6 ± 4.7; p = 0.010). There was no statistically significant difference in how LS novices and LS experienced surgeons performed in RAS [Mean (SD): novices: 48.9 ± 9.0; experienced surgeons: 55.9 ± 11.0; p = 0.540]. Mental and physical demand was significantly higher after LS.

CONCLUSION

The initial performance was improved for RAS versus LS for linear stapled bowel anastomosis, whereas workload was higher for LS. There was limited transfer of skills from LS to RAS.

Unpacking the Broad Landscape of Intraoperative Stressors for Clinical Personnel: A Mixed-Methods Systematic Review

Purpose

The main goals of this mixed-methods systematic review are to identify what types of intraoperative stressors for operating room personnel have been reported in collected studies and examine the characteristics of each intraoperative stressor.

Methods

With a systematic literature search, we retrieved empirical studies examining intraoperative stress published between 2010 and 2020. To synthesize findings, we applied two approaches. First, a textual narrative synthesis was employed to summarize key study information of the selected studies by focusing on surgical platforms and study participants. Second, a thematic synthesis was employed to identify and characterize intraoperative stressors and their subtypes.

Results

Ninety-four studies were included in the review. Regarding the surgical platforms, the selected studies mainly focused on minimally invasive surgery and few studies examined issues around robotic surgery. Most studies examined intra-operative stress from surgeons' perspectives but rarely considered other clinical personnel such as nurses and anesthetists. Among seven identified stressors, technical factors were the most frequently examined followed by individual, operating room environmental, interpersonal, temporal, patient, and organizational factors.

Conclusion

By presenting stressors as multifaceted elements affecting collaboration and interaction between multidisciplinary team members in the operating room, we discuss the potential interactions between stressors which should be further investigated to build a safe and efficient environment for operating room personnel.

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.

Using Digital Biomarkers for Objective Assessment of Perfusionists' Workload and Acute Stress During Cardiac Surgery

The cardiac operating room (OR) is a high-risk, high-stakes environment inserted into a complex socio-technical healthcare system. During cardiopulmonary bypass (CPB), the most critical phase of cardiac surgery, the perfusionist has a crucial role within the interprofessional OR team, being responsible for optimizing patient perfusion while coordinating other tasks with the surgeon, anesthesiologist, and nurses. The aim of this study was to investigate objective digital biomarkers of perfusionists' workload and stress derived from heart rate variability (HRV) metrics captured via a wearable physiological sensor in a real cardiac OR. We explored the relationships between several HRV parameters and validated self-report measures of surgical task workload (SURG-TLX) and acute stress (STAI-SF), as well as surgical processes and outcome measures. We found that the frequency-domain HRV parameter HF relative power - FFT (%) presented the strongest association with task workload (correlation coefficient: -0.491, p-value: 0.003). We also found that the time-domain HRV parameter RMSSD (ms) presented the strongest correlation with perfusionists' acute stress (correlation coefficient: -0.489, p-value: 0.005). A few workload and stress biomarkers were also associated with bypass time and patient length of stay in the hospital. The findings from this study will inform future research regarding which HRV-based biomarkers are best suited for the development of cognitive support systems capable of monitoring surgical workload and stress in real time.

Cognitive Load Assessment Scales in Simulation: Validity Evidence for a Novel Measure of Cognitive Load Types

INTRODUCTION

Cognitive load (CL) theory provides a framework to inform simulation instructional design. Reliable measures of CL types (intrinsic [IL], extraneous [EL], and germane load [GL]) in simulation are lacking. We developed the novel Cognitive Load Assessment Scales in Simulation (CLAS-Sim) and report validity evidence using Kane's framework.

METHODS

This quasi-experimental study tested the effect of a segmented/pause-and-debrief or standard/end-of-case-debrief intervention on pediatric residents' performance and self-rated CL in 2 complex- and simple-case simulations. After each simulation, participants completed 22 items measuring CL types. Three validity inferences were examined: scoring (instrument development and principal component analysis); generalization (internal consistency reliability of CL-component items across cases); and extrapolation [CLAS-Sim correlations with the single-item Paas scale, which measures overall CL; differences in primary task performance (high vs low); and discriminant validity of IL under different instructional-design conditions].

RESULTS

Seventy-four residents completed both simulations and postcase CLAS-Sim measures. The principal component analysis yielded 3 components: 4-item IL, 4-item EL, and 3-item GL scales (Cronbach's α, 0.68-0.77). The Paas scores correlated with CLAS-Sim IL and total CL scores in both cases ( rs range, 0.39-0.70; P ≤ 0.001). High complex-case performers reported lower IL and total CL (analyses of variance, each P < 0.001). In multivariate analyses of variance, CLAS-Sim IL, GL, and total CL varied across both cases by arm (each P ≤ 0.018); the segmented-debrief arm reported lower IL than the standard-debrief arm in both cases (each P ≤ 0.01).

CONCLUSIONS

The CLAS-Sim demonstrates preliminary validity evidence for distinguishing 3 CL types but requires further study to evaluate the impact of simulation-design elements on CL and learning.

Persistent effects of mobile phone conversation while driving after disconnect: Physiological evidence and driving performance

Cognitive workload has been known as a key factor in traffic accidents, which can be highly increased by talking on the phone while driving. A wide range of studies around the world investigated the effects of mobile phone conversations on driving performance and traffic accidents. But less noticed is the durability of cognitive effects of mobile phone conversations. This study aimed to determine the effects of different types of mobile phone conversations on physiological response and driving performance during and after the conversation. Heart rate, heart rate variability (physiological response), Standard deviation of lane position (SDLP), and the relative distance between two cars (driving performance) of 34 samples (male and female) in the driving simulator were recorded. In this study, three types of conversations (neutral, cognitive, and arousal) were used. Neutral conversation did not pursue specific purpose questions. Cognitive conversations were simple mathematical problem-solving questions and arousal conversations aimed at arousing participant emotions. Each conversation was used as a secondary task in a condition. The study had three conditions; in each condition the participant drove for 15 min. Each condition consisted of 5 min of driving (Background), 5 min of driving and conversation (dual tasks) and 5 min of driving after conversation to trace the effects of the conversation. Vehicle speed was 110 km/h in each of the three conditions using car-following scenario. The results showed that neutral conversations had no significant effects on physiological response. Though, arousal conversations had significant effects on physiological responsiveness and driving performance during conversations, where it was even more significant after disconnection. Therefore, the content of the conversation determines the amount of cognitive load imposed on the driver. Considering the persistence of cognitive effects caused by conversation, the risk of traffic accidents is still high even after disconnection.

Measuring cognitively demanding activities in pediatric out-of-hospital cardiac arrest

BACKGROUND

This methodological intersection article demonstrates a method to measure cognitive load in clinical simulations. Researchers have hypothesized that high levels of cognitive load reduce performance and increase errors. This phenomenon has been studied primarily by experimental designs that measure responses to predetermined stimuli and self-reports that reduce the experience to a summative value. Our goal was to develop a method to identify clinical activities with high cognitive burden using physiologic measures.

METHODS

Teams of emergency medical responders were recruited from local fire departments to participate in a scenario with a shockable pediatric out-of-hospital cardiac arrest (POHCA) patient. The scenario was standardized with the patient being resuscitated after receiving high-quality CPR and 3 defibrillations. Each team had a person in charge (PIC) who wore a functional near-infrared spectroscopy (fNIRS) device that recorded changes in oxygenated and deoxygenated hemoglobin concentration in their prefrontal cortex (PFC), which was interpreted as cognitive activity. We developed a data processing pipeline to remove nonneural noise (e.g., motion artifacts, heart rate, respiration, and blood pressure) and detect statistically significant changes in cognitive activity. Two researchers independently watched videos and coded clinical tasks corresponding to detected events. Disagreements were resolved through consensus, and results were validated by clinicians.

RESULTS

We conducted 18 simulations with 122 participants. Participants arrived in teams of 4 to 7 members, including one PIC. We recorded the PIC's fNIRS signals and identified 173 events associated with increased cognitive activity. [Defibrillation] (N = 34); [medication] dosing (N = 33); and [rhythm checks] (N = 28) coincided most frequently with detected elevations in cognitive activity. [Defibrillations] had affinity with the right PFC, while [medication] dosing and [rhythm checks] had affinity with the left PFC.

CONCLUSIONS

FNIRS is a promising tool for physiologically measuring cognitive load. We describe a novel approach to scan the signal for statistically significant events with no a priori assumptions of when they occur. The events corresponded to key resuscitation tasks and appeared to be specific to the type of task based on activated regions in the PFC. Identifying and understanding the clinical tasks that require high cognitive load can suggest targets for interventions to decrease cognitive load and errors in care.

The Evidence Basis for Learning Theory and Technology in Surgical Skills Training

Orthopaedic trainees face a complex and challenging training environment that is currently becoming more competency driven. Associated with these changes are an increasing introduction and use of a variety of technologically driven surgical training augments. Although these new learning resources can positively transform the educational environment, they must be used appropriately by both learners and educators. To aid in this, we review learning theories because they apply to surgical skills training and highlight recent surgical training evidence that demonstrates how technology use can be optimized to promote surgical learning, with an emphasis on procedural learning theory and cognitive load theory. Specifically, we review the evidence demonstrating the importance of targeting technology to a learner's experience level and methods to optimize cognitive load by managing intrinsic load, minimizing extraneous load, and maximizing germane load.

An Open-Source, Interoperable Architecture for Generating Real-Time Surgical Team Cognitive Alerts from Heart-Rate Variability Monitoring

Clinical alarm and decision support systems that lack clinical context may create non-actionable nuisance alarms that are not clinically relevant and can cause distractions during the most difficult moments of a surgery. We present a novel, interoperable, real-time system for adding contextual awareness to clinical systems by monitoring the heart-rate variability (HRV) of clinical team members. We designed an architecture for real-time capture, analysis, and presentation of HRV data from multiple clinicians and implemented this architecture as an application and device interfaces on the open-source OpenICE interoperability platform. In this work, we extend OpenICE with new capabilities to support the needs of the context-aware OR including a modularized data pipeline for simultaneously processing real-time electrocardiographic (ECG) waveforms from multiple clinicians to create estimates of their individual cognitive load. The system is built with standardized interfaces that allow for free interchange of software and hardware components including sensor devices, ECG filtering and beat detection algorithms, HRV metric calculations, and individual and team alerts based on changes in metrics. By integrating contextual cues and team member state into a unified process model, we believe future clinical applications will be able to emulate some of these behaviors to provide context-aware information to improve the safety and quality of surgical interventions.