Guiding navigation in colonoscopy

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.

Hands-free administration of subjective workload scales: acceptability in a surgical training environment

INTRODUCTION

Subjective workload measures are usually administered in a visual-manual format, either electronically or by paper and pencil. However, vocal responses to spoken queries may sometimes be preferable, for example when experimental manipulations require continuous manual responding or when participants have certain sensory/motor impairments. In the present study, we evaluated the acceptability of the hands-free administration of two subjective workload questionnaires - the NASA Task Load Index (NASA-TLX) and the Multiple Resources Questionnaire (MRQ) - in a surgical training environment where manual responding is often constrained.

METHOD

Sixty-four undergraduates performed fifteen 90-s trials of laparoscopic training tasks (five replications of 3 tasks - cannulation, ring transfer, and rope manipulation). Half of the participants provided workload ratings using a traditional paper-and-pencil version of the NASA-TLX and MRQ; the remainder used a vocal (hands-free) version of the questionnaires. A follow-up experiment extended the evaluation of the hands-free version to actual medical students in a Minimally Invasive Surgery (MIS) training facility.

RESULTS

The NASA-TLX was scored in 2 ways - (1) the traditional procedure using participant-specific weights to combine its 6 subscales, and (2) a simplified procedure - the NASA Raw Task Load Index (NASA-RTLX) - using the unweighted mean of the subscale scores. Comparison of the scores obtained from the hands-free and written administration conditions yielded coefficients of equivalence of r=0.85 (NASA-TLX) and r=0.81 (NASA-RTLX). Equivalence estimates for the individual subscales ranged from r=0.78 ("mental demand") to r=0.31 ("effort"). Both administration formats and scoring methods were equally sensitive to task and repetition effects. For the MRQ, the coefficient of equivalence for the hands-free and written versions was r=0.96 when tested on undergraduates. However, the sensitivity of the hands-free MRQ to task demands (η(partial)(2)=0.138) was substantially less than that for the written version (η(partial)(2)=0.252). This potential shortcoming of the hands-free MRQ did not seem to generalize to medical students who showed robust task effects when using the hands-free MRQ (η(partial)(2)=0.396). A detailed analysis of the MRQ subscales also revealed differences that may be attributable to a "spillover" effect in which participants' judgments about the demands of completing the questionnaires contaminated their judgments about the primary surgical training tasks.

CONCLUSION

Vocal versions of the NASA-TLX are acceptable alternatives to standard written formats when researchers wish to obtain global workload estimates. However, care should be used when interpreting the individual subscales if the object is to make comparisons between studies or conditions that use different administration modalities. For the MRQ, the vocal version was less sensitive to experimental manipulations than its written counterpart; however, when medical students rather than undergraduates used the vocal version, the instrument's sensitivity increased well beyond that obtained with any other combination of administration modality and instrument in this study. Thus, the vocal version of the MRQ may be an acceptable workload assessment technique for selected populations, and it may even be a suitable substitute for the NASA-TLX.

Spatial Mental Representation: Implications for Navigation System Design

Similarities exist in how people process and represent spatial information and in the factors that contribute to disorientation, whether one is moving through airspace, on the ground, or surgically within the body. As such, design principles for presenting spatial information should bear similarities across these domains but also be somewhat specific to each. In this chapter, we review research in spatial cognition and its application to navigation system design for within-vehicle, aviation, and endoscopic navigation systems. Taken together, the research suggests three general principles for navigation system design consideration. First, multimedia displays should present spatial information visually and action and description information verbally. Second, display organizations should meet users' dynamic navigational goals. Third, navigation systems should be adaptable to users' spatial information preferences. Designers of adaptive navigation display technologies can maximize the effectiveness of those technologies by appealing to the basic spatial cognition processes employed by all users while conforming to user's domain-specific requirements.