Surgeons' expertise during critical event in laparoscopic cholecystectomy: An expert-novice comparison using protocol analysis.

BACKGROUND: The purpose of this study was to examine differences in thought processes between novice and experienced surgeons when they were presented with a critical situation during laparoscopic cholecystectomy. METHODS: A group of experienced and novice surgeons were shown a recording of a laparoscopic cholecystectomy with an intraoperative bleeding event. The think-aloud method was used to capture surgeons' thought processes. Verbal reports were recorded, transcribed and analyzed using the protocol analysis method. RESULTS: Sixteen subjects (8 in each group) participated at two centers. Experienced surgeons demonstrated deeper comprehension of the operative field, richer mental image of future events and superior awareness of potentially dangerous situations. They also spent more time engaged in metacognitive activity. CONCLUSIONS: This study highlights the differences and similarities between surgeons with different levels of experience during a challenging intraoperative encounter. The domains of cognition and mental image as well as metacognition appear to be key elements of surgical expertise.

Faculty feedback versus residents' self-assessment of operative performance: Different but complementary.

BACKGROUND: Surgical training requires development of both technical and cognitive skills. The study analyzed feedback by faculty and residents' self-assessments during a laparoscopic training course to identify structure of feedback in this context and compared the focus of trainees to faculty. METHODS: This study collected assessments by surgical residents and faculty during an intensive laparoscopic training course at a single institution. The residents' operative performance was assessed using validated assessment tools including free text feedback. Assessments were completed immediately following procedures. Feedback was analyzed using qualitative method. RESULTS: Eighty (80) residents participated. Three themes were identified: Assessment, instruction and occasion. Faculty provided significantly more feedback than trainees. Moreover, the content of feedback was different. Residents focused on technical performance, while faculty commented on technical and cognitive skills, efficiency and level of independence. Errors were mainly addressed by faculty. CONCLUSION: This study demonstrated differences in cognitive focus of trainees and faculty. Text feedback is informative in understanding perceived challenges. Faculty provided explicit assessment and instruction for improvement. The effectiveness of self-assessment and feedback should be further studied.

Laterality of central venous sampling: lack of effect on the accuracy of intraoperative parathyroid hormone monitoring.

BACKGROUND: The purpose of this study was to determine if laterality of internal jugular vein (IJV) sampling affects the accuracy of intraoperative parathyroid hormone (PTH) monitoring during parathyroidectomy for primary hyperparathyroidism. METHODS: In this study, 109 patients underwent parathyroidectomy (82 with unilateral disease, 27 with multigland disease). PTH samples were taken from both the left and the right IJV at these time points: preincision (baseline) and then at 5, 10, and, in selected patients, 20 minutes after excision. The Miami criterion was used to determine operative success. RESULTS: In all 109 patients combined, the mean decreases in intraoperative PTH levels were 73.8 ± 22.2% for the left IJV and 71.9 ± 23.0% for the right IJV (P = .22). The Miami criterion was met in 105 patients: in 100 (95%) left IJV samples and 99 (94%) right IJV samples (P = 1.00). CONCLUSIONS: No difference was found in the accuracy of intraoperative PTH monitoring between patients' left and right IJV samples. Central venous laterality did not affect fulfillment of the Miami criterion.