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Expertise Differences in Fixation, Quiet Eye Duration, and Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve. Harvey, A. 1 Vickers, JN. 2 Snelgrove, R. 1 Scott, M. 2 & Morrison, S. 2 Department of Surgery 1 Faculty of Kinesiology 2

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Expertise Differences in Fixation, Quiet Eye Duration, and Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve

Harvey, A.1 Vickers, JN. 2 Snelgrove, R. 1 Scott, M. 2 & Morrison, S. 2

Department of Surgery 1

Faculty of Kinesiology 2

Association of Surgical Education

Orlando, Florida

April 24, 2013

1

2


Background
Background Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve

  • Halsted Model

    • Apprenticeship Based

    • Graded Responsibility

2


Background1
Background Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve

  • High level athlete gaze, focus of attention, and relation to motor skill has been studied for years

  • Extensive research in sport on the Quiet Eye (QE)

  • Over 70 refereed studies to date in over 15 sports

Quiet eye

location

4


Background2
Background Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve

  • Quiet eye fixation = fixation on a specific location within 1 degree of visual angle (foveal vision) for more than 100 ms prior to successful completion of a critical movement

  • Elite performers have longer duration quiet eye characteristic

  • Quiet eye is also longer during high levels of performance

  • QE training has proven successful in a wide range of sports


Background3
Background Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve

  • Limited literature focus of attention in surgical skills acquirement or training

  • Moulton et al – “Slowing Down” at critical moments


Purpose
Purpose Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve

  • To examine the surgical movements, fixation durations, and Quiet Eye durations of highly experienced (HE) & less experienced (LE) surgeons/residents

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Hypotheses
Hypotheses Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve

  • HE surgeons will be ranked higher than LE surgeons (blinded external review)

  • HE surgeons will ‘slow down’ using longer Quiet Eye durations on the Recurrent Laryngeal Nerve

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Methods
Methods Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve

  • Ten Volunteers

    • 3 HE surgeons (M = 2391 operations)

    • 7 LE surgeons (M = 37 operations)

  • Equipment

    • ASL mobile eye tracker

    • Synchronized external video of surgical movements

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Surgical movements and gaze data
Surgical Movements and Gaze Data Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve

Surgical Movements

Gaze Data


11 Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve


Results global rating scores
Results – Global Rating Scores Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve

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Results global rating score respect for tissue x phase
Results – Global Rating Score Surgical Performance During Identification and Dissection of the Recurrent Laryngeal NerveRespect for Tissue x Phase

Phase 1: Identify Inferior Thyroid Artery

Phase 2: Identify Recurrent Laryngeal Nerve

Phase 3: Divide Ligament of Berry

p < .04

13

13


Results movement time mt
Results – Movement Time (MT%) Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve

p < .98

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Total fixation duration by phase
Total Fixation Duration by Phase Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve


Quiet eye qe duration on recurrent laryngeal nerve
Quiet Eye (QE) Duration on Recurrent Laryngeal Nerve Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve

p < .008

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Summary
Summary Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve

  • Relative to LE, HE surgeons had:

    • Higher global rating scores

    • No significant differences in operating time, or hand movement times (MT%)

    • Longer fixation durations on the Ligament of Berry

    • Higher QE duration on the RLN prior to blunt and sharp dissections

17


Conclusions
Conclusions Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve

  • HE surgeon’s longer QE duration reveals greater focus of attention on critical structures prior to and during surgical movements

  • HE surgeon’s longer fixations on the LofB suggest the use of a perceptual anchor that is used to define the underlying structures

  • HE surgeonscognitivelyslow down during critical phases of the operation

  • Moulton & Epstein are correct, “slowing down” is a critical cognitive skill of expert surgeons


Future directions
Future Directions Surgical Performance During Identification and Dissection of the Recurrent Laryngeal Nerve

  • Quiet Eye Training

    • Durable

    • Robust under conditions of stress/anxiety

    • Increases success under conditions of exhaustion

  • July 2013 – knot tying for R1 surgical residents


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