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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
  • Halsted Model
    • Apprenticeship Based
    • Graded Responsibility

2

background1
Background
  • 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
  • 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
  • Limited literature focus of attention in surgical skills acquirement or training
  • Moulton et al – “Slowing Down” at critical moments
purpose
Purpose
  • To examine the surgical movements, fixation durations, and Quiet Eye durations of highly experienced (HE) & less experienced (LE) surgeons/residents

7

hypotheses
Hypotheses
  • 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

8

methods
Methods
  • 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

9

surgical movements and gaze data
Surgical Movements and Gaze Data

Surgical Movements

Gaze Data

results global rating score respect for tissue x phase
Results – Global Rating ScoreRespect for Tissue x Phase

Phase 1: Identify Inferior Thyroid Artery

Phase 2: Identify Recurrent Laryngeal Nerve

Phase 3: Divide Ligament of Berry

p < .04

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summary
Summary
  • 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
  • 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
  • Quiet Eye Training
    • Durable
    • Robust under conditions of stress/anxiety
    • Increases success under conditions of exhaustion
  • July 2013 – knot tying for R1 surgical residents