Top

Published in:

01-07-2016

Skill acquisition and stress adaptations following laparoscopic surgery training and detraining in novice surgeons

Authors: Blair T. Crewther, Kunal Shetty, Delaram Jarchi, Shaun Selvadurai, Christian J. Cook, Daniel R. Leff, Ara Darzi, Guang-Zhong Yang

Published in: Surgical Endoscopy | Issue 7/2016

Abstract

Background

Surgical training and practice is stressful, but adaptive changes in the stress circuitry (e.g. perceptual, physiological, hormonal, neural) could support skill development. This work examined skill acquisition and stress adaptations in novice surgeons during laparoscopic surgery (LS) training and detraining.

Methods

Twelve medical students were assessed for skill performance after 2 h (BASE), 5 h (MID) and 8 h (POST) of LS training in weeks 1–3, and then after 4 weeks of no training (RETEST). The stress outcomes included state anxiety, perceived stress and workload, heart rate (HR), heart rate variability (HRV), and salivary testosterone and cortisol concentrations. Functional near-infrared spectroscopy was used to assess cortical oxygenation change, as a marker of prefrontal cortex (PFC) activity.

Results

Skill performance improved in every session from BASE (p < 0.01), with corresponding decreases in state anxiety, stress, workload, low- and high-frequency HRV in the MID, POST and/or RETEST sessions (p < 0.05). Left and right PFC were symmetrically activated within each testing session (p < 0.01). The stress and workload measures predicted skill performance and changes over time (p < 0.05), with state anxiety, mean HR and the HRV measures also showing some predictive potential (p < 0.10).

Conclusions

A 3-week LS training programme promoted stress-related adaptations likely to directly, or indirectly, support the acquisition of new surgical skills, and many outcomes were retained after a 4-week period without further LS training. These results have implications for medical training and education (e.g. distributed training for skill development and maintenance, stress resource and management training) and highlighted possible areas for new research (e.g. longitudinal stress and skill profiling).

Arora S, Sevdalis N, Nestel D, Woloshynowych M, Darzi A, Kneebone R (2010) The impact of stress on surgical performance: a systematic review of the literature. Surgery 147:318–330CrossRefPubMed

Leblanc VR (2009) The effects of acute stress on performance: implications for health professions education. Acad Med 84:S25–S33CrossRefPubMed

Cerqueira JJ, Almeida OF, Sousa N (2008) The stressed prefrontal cortex. Left? Right? Brain Behav Immun 22:630–638CrossRefPubMed

Leff DR, Orihuela-Espina F, Atallah L, Athanasiou T, Leong JJ, Darzi AW, Yang GZ (2008) Functional prefrontal reorganization accompanies learning-associated refinements in surgery: a manifold embedding approach. Comput Aided Surg 13:325–339CrossRefPubMed

Kelly AMC, Garavan H (2005) Human functional neuroimaging of brain changes associated with practice. Cereb Cortex 15:1089–1102CrossRefPubMed

Arora S, Sevdalis N, Aggarwal R, Sirimanna P, Darzi A, Kneebone R (2010) Stress impairs psychomotor performance in novice laparoscopic surgeons. Surg Endosc 24:2588–2593CrossRefPubMed

Schuetz M, Gockel I, Beardi J, Hakman P, Dunschede F, Moenk S, Heinrichs W, Junginger T (2008) Three different types of surgeon-specific stress reactions identified by laparoscopic simulation in a virtual scenario. Surg Endosc 22:1263–1267CrossRefPubMed

Arora S, Aggarwal R, Moran A, Sirimanna P, Crochet P, Darzi A, Kneebone R, Sevdalis N (2011) Mental practice: effective stress management training for novice surgeons. J Am Coll Surg 212:225–233CrossRefPubMed

Böhm B, Rötting N, Schwenk W, Grebe S, Mansmann U (2001) A prospective randomized trial on heart rate variability of the surgical team during laparoscopic and conventional sigmoid resection. Arch Surg 136:305–310CrossRefPubMed

10.

Klein MI, Warm JS, Riley MA, Matthews G, Doarn C, Donovan JF, Gaitonde K (2012) Mental workload and stress perceived by novice operators in the laparoscopic and robotic minimally invasive surgical interfaces. J Endourol 26:1089–1094CrossRefPubMed

11.

Leff DR, Orihuela-Espina F, Elwell CE, Athanasiou T, Delpy DT, Darzi AW, Yang GZ (2011) Assessment of the cerebral cortex during motor task behaviours in adults: a systematic review of functional near infrared spectroscopy (fNIRS) studies. Neuroimage 54:2922–2936CrossRefPubMed

12.

Ohuchida K, Kenmotsu H, Yamamoto A, Sawada K, Hayami T, Morooka K, Takasugi S, Konishi K, Ieiri S, Tanoue K, Iwamoto Y, Tanaka M, Hashizume M (2009) The frontal cortex is activated during learning of endoscopic procedures. Surg Endosc 23:2296–2301CrossRefPubMed

13.

Orihuela-Espina F, Leff DR, James DRC, Darzi AW, Yang GZ (2010) Quality control and assurance in functional near infrared spectroscopy (fNIRS) experimentation. Phys Med Biol 55:1–24CrossRef

14.

Cope M, Delpy DT (1988) System for long-term measurement of cerebral blood and tissue oxygenation on newborn infants by near infra-red transillumination. Med Biol Eng Comput 26:289–294CrossRefPubMed

15.

Yamaguchi S, Yoshida D, Kenmotsu H, Yasunaga T, Konishi K, Ieiri S, Nakashima H, Tanoue K, Hashizume M (2011) Objective assessment of laparoscopic suturing skills using a motion-tracking system. Surg Endosc 25:771–775CrossRefPubMed

16.

Malhotra N, Poolton JM, Wilson MR, Ngo K, Masters RSW (2012) Conscious monitoring and control (reinvestment) in surgical performance under pressure. Surg Endosc 26:2423–2429CrossRefPubMedPubMedCentral

17.

Yamamoto A, Hara T, Kikuchi K, Hara T, Fujiwara T (1999) Intraoperative stress experienced by surgeons and assistants. Ophthalmic Surg Lasers 30:27–30PubMed

18.

Arora S, Tierney T, Sevdalis N, Aggarwal R, Nestel D, Woloshynowych M, Darzi A, Kneebone R (2010) The Imperial Stress Assessment Tool (ISAT): a feasible, reliable and valid approach to measuring stress in the operating room. World J Surg 34:1756–1763CrossRefPubMed

19.

Alobid I, de Pablo J, Mullol J, Centellas S, Parramon G, Carrasco J, Armario A, Bernal-Sprekelsen M (2011) Increased cardiovascular and anxiety outcomes but not endocrine biomarkers of stress during performance of endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg 137:487–492CrossRefPubMed

20.

Korndorffer JR Jr, Dunne JB, Sierra R, Stefanidis D, Touchard CL, Scott DJ (2005) Simulator training for laparoscopic suturing using performance goals translates to the operating room. J Am Coll Surg 201:23–29CrossRefPubMed

21.

Marteau T, Bekker H (1992) The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI). Br J Clin Psychol 31:301–306CrossRefPubMed

22.

Hart SG (2006) NASA-Task Load Index (NASA-TLX); 20 years later. In: Human factors and ergonomics society annual meeting proceedings, San Francisco, pp 904–908

23.

Orihuela-Espina F, Leff DR, James DR, Darzi AW, Yang GZ (2009) ICNA: a software tool for manifold embedded based analysis of functional near infrared spectroscopy data. In: 15th annual meeting of the organization for human brain mapping, San Francisco, California, USA

24.

Gröschl M (2008) Current status of salivary hormone analysis. Clin Chem 54:1759–1769CrossRefPubMed

25.

Ishikawa W, Sato M, Fukuda Y, Matsumoto T, Takemura N, Sakatani K (2014) Correlation between asymmetry of spontaneous oscillation of hemodynamic changes in the prefrontal cortex and anxiety levels: a near-infrared spectroscopy study. J Biomed Opt 19:027005. doi:10.1117/1111.JBO.1119.1112 CrossRefPubMed

26.

Liang K-Y, Zeger SL (1986) Longitudinal data analysis using generalized linear models. Biometrika 73:13–22CrossRef

27.

Chaudhry A, Sutton C, Wood J, Stone R, McClow R (1999) Learning rate for laparoscopic surgical skills on MIST VR, a virtual reality simulator: quality of human–computer interface. Ann R Coll Surg Engl 81:281–286PubMedPubMedCentral

28.

Gallagher AG, Jordan-Black JA, O’Sullivan GC (2012) Prospective, randomized assessment of the acquisition, maintenance, and loss of laparoscopic skills. Ann Surg 256:387–393CrossRefPubMed

29.

Prabhu A, Smith W, Yurko Y, Acker C, Stefanidis D (2010) Increased stress levels may explain the incomplete transfer of simulator-acquired skill to the operating room. Surgery 147:640–645CrossRefPubMed

30.

Vine SJ, Freeman P, Moore LJ, Chandra-Ramanan R, Wilson MR (2013) Evaluating stress as a challenge is associated with superior attentional control and motor skill performance: testing the predictions of the biopsychosocial model of challenge and threat. J Exp Psychol Appl 19:185–194CrossRefPubMed

31.

Bouarfa L, Bembnowicz P, Crewther B, Jarchi D, Yang G-Z (2013) Profiling visual and verbal stress responses using electrodermal, heart rate and hormonal measures. In: IEEE body sensor network conference, MIT, Cambridge, Massachusetts pp 1–7

32.

James DR, Leff DR, Orihuela-Espina F, Kwok KW, Mylonas GP, Athanasiou T, Darzi AW, Yang GZ (2013) Enhanced frontoparietal network architectures following “gaze-contingent” versus “free-hand” motor learning. Neuroimage 64:267–276CrossRefPubMed

33.

Rémy F, Wenderoth N, Lipkens K, Swinnen SP (2008) Acquisition of a new bimanual coordination pattern modulates the cerebral activations elicited by an intrinsic pattern: an fMRI study. Cortex 44:482–493CrossRefPubMed

34.

Debaere F, Wenderoth N, Sunaert S, Van Hecke P, Swinnen SP (2004) Changes in brain activation during the acquisition of a new bimanual coordination task. Neuropsychologia 42:855–867CrossRefPubMed

35.

Petersen SE, van Mier H, Fiez JA, Raichle ME (1998) The effects of practice on the functional anatomy of task performance. Proc Natl Acad Sci USA 95:853–860CrossRefPubMedPubMedCentral

36.

Maan ZN, Maan IN, Darzi AW, Aggarwal R (2012) Systematic review of predictors of surgical performance. Br J Surg 99:1610–1621CrossRefPubMed

37.

Wetzel CM, George A, Hanna GB, Athanasiou T, Black SA, Kneebone RL, Nestel D, Woloshynowych M (2011) Stress management training for surgeons—a randomized, controlled, intervention study. Ann Surg 253:488–494CrossRefPubMed

38.

Moore LJ, Vine SJ, Wilson MR, Freeman P (2014) Examining the antecedents of challenge and threat states: the influence of perceived required effort and support availability. Int J Psychophysiol 93:267–273CrossRefPubMed

Title: Skill acquisition and stress adaptations following laparoscopic surgery training and detraining in novice surgeons
Authors: Blair T. Crewther
Kunal Shetty
Delaram Jarchi
Shaun Selvadurai
Christian J. Cook
Daniel R. Leff
Ara Darzi
Guang-Zhong Yang
Publication date: 01-07-2016
Publisher: Springer US
Published in: Surgical Endoscopy / Issue 7/2016
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-015-4584-0

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Skill acquisition and stress adaptations following laparoscopic surgery training and detraining in novice surgeons

Abstract

Background

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 7/2016

A multi-modal approach to training in laparoscopic colorectal surgery accelerates proficiency gain

Long-term outcomes of cruroplasty reinforcement with composite versus biologic mesh for gastroesophageal reflux disease

Liver retraction system by C3-muco-adhesive polymer films for laparoscopic surgery

Electrothermal bipolar vessel ligation improves operative time during laparoscopic total proctocolectomy: a large single-center experience

An experimental study in six fresh human cadavers using a novel approach to avoid abdominal wall incisions in total colectomy: totally transanal laparoendoscopic single-site pull-through colectomy with J-pouch creation

Traction with dental floss and endoscopic clip improves trainee success in performing gastric endoscopic submucosal dissection (ESD): a live porcine study (with video)