Toward scar-free surgery: an analysis of the increasing complexity from laparoscopic surgery to NOTES

The use of cognitive task analysis in clinical and health services research — a systematic review

Background

At times, clinical case complexity and different types of uncertainty present challenges to less experienced clinicians or the naive application of clinical guidelines where this may not be appropriate. Cognitive task analysis (CTA) methods are used to elicit, document and transfer tacit knowledge about how experts make decisions.

Methods

We conducted a methodological review to describe the use of CTA methods in understanding expert clinical decision-making. We searched MEDLINE, EMBASE and PsycINFO from inception to 2019 for primary research studies which described the use of CTA methods to understand how qualified clinicians made clinical decisions in real-world clinical settings.

Results

We included 81 articles (80 unique studies) from 13 countries, published from 1993 to 2019, most commonly from surgical and critical care settings. The most common aims were to understand expert decision-making in particular clinical scenarios, using expert decision-making in the development of training programmes, understanding whether decision support tools were warranted and understanding procedural variability and error identification or reduction. Critical decision method (CDM) and CTA interviews were most frequently used, with hierarchical task analysis, task knowledge structures, think-aloud protocols and other methods less commonly used. Studies used interviews, observation, think-aloud exercises, surveys, focus groups and a range of more CTA-specific methodologies such as the systematic human error reduction and prediction approach. Researchers used CTA methods to investigate routine/typical (n = 64), challenging (n = 13) or more uncommon, rare events and anomalies (n = 3).

Conclusions

In conclusion, the elicitation of expert tacit knowledge using CTA has seen increasing use in clinical specialties working under challenging time pressures, complexity and uncertainty. CTA methods have great potential in the development, refinement, modification or adaptation of complex interventions, clinical protocols and practice guidelines.

Registration

PROSPERO ID CRD42019128418.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01002-6.

vNOTES for adnexal procedures

This work aims to describe the technique and review all transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for adnexal procedures performed and to acknowledge vNOTES as an alternative to conventional laparoscopy. The procedure consisted of an incision in the Pouch of Douglas, insertion of a single port device, laparoscopic surgery through the device, extraction of specimens through the vagina and closure of the vaginal apex with a direct suture. Eighteen procedures have been successfully completed, 1 patient required conversion to conventional abdominal surgery due to intolerance to pneumoperitoneum. Surgeries' length range was 45-210 minutes. The estimated blood loss was less than 100 mL. The patients required minimal analgesia, were discharged the day after and had no postoperative complications. No patients complained of dyspareunia. Two patients conceived after surgery. vNOTES is a safe and desirable approach to the adnexa and a reasonable alternative to conventional laparoscopy or vaginal surgery.Impact statementWhat is already known on this subject? Natural Orifice Transluminal Surgery (NOTES) is a technique used to access the abdominal cavity through natural orifice. Compared to conventional laparoscopy, it's expected to have fewer complications.What do the results of this study add? This is one of the few works addressing vNOTES adnexal surgery, which appears to be a good alternative to conventional laparoscopy.What are the implications of these findings for clinical practice and/or further research? vNOTES may be a desirable approach to the adnexa. This work opens a door to new research regarding vNOTES in more complex gynaecologic procedures.

Achieving Interface and Environment Fidelity in the Virtual Basic Laparoscopic Surgical Trainer

Virtual reality trainers are educational tools with great potential for laparoscopic surgery. They can provide basic skills training in a controlled environment and free of risks for patients. They can also offer objective performance assessment without the need for proctors. However, designing effective user interfaces that allow the acquisition of the appropriate technical skills on these systems remains a challenge. This paper aims to examine a process for achieving interface and environment fidelity during the development of the Virtual Basic Laparoscopic Surgical Trainer (VBLaST). Two iterations of the design process were conducted and evaluated. For that purpose, a total of 42 subjects participated in two experimental studies in which two versions of the VBLaST were compared to the accepted standard in the surgical community for training and assessing basic laparoscopic skills in North America, the FLS box-trainer. Participants performed 10 trials of the peg transfer task on each trainer. The assessment of task performance was based on the validated FLS scoring method. Moreover, a subjective evaluation questionnaire was used to assess the fidelity aspects of the VBLaST relative to the FLS trainer. Finally, a focus group session with expert surgeons was conducted as a comparative situated evaluation after the first design iteration. This session aimed to assess the fidelity aspects of the early VBLaST prototype as compared to the FLS trainer. The results indicate that user performance on the earlier version of the VBLaST resulting from the first design iteration was significantly lower than the performance on the standard FLS box-trainer. The comparative situated evaluation with domain experts permitted us to identify some issues related to the visual, haptic and interface fidelity on this early prototype. Results of the second experiment indicate that the performance on the second generation VBLaST was significantly improved as compared to the first generation and not significantly different from that of the standard FLS box-trainer. Furthermore, the subjects rated the fidelity features of the modified VBLaST version higher than the early version. These findings demonstrate the value of the comparative situated evaluation sessions entailing hands on reflection by domain experts to achieve the environment and interface fidelity and training objectives when designing a virtual reality laparoscopic trainer. This suggests that this method could be used successfully in the future to enhance the value of VR systems as an alternative to physical trainers for laparoscopic surgery skills. Some recommendations on how to use this method to achieve the environment and interface fidelity of a VR laparoscopic surgical trainer are identified.