The Association for Surgical Education| Volume 203, ISSUE 1, P37-43, January 2012

Sleep deprivation increases cognitive workload during simulated surgical tasks

Published:November 14, 2011DOI:



      There have been conflicting reports of the effects of modest sleep deprivation on surgical skills. The aim of this study was to assess the effects of a 24-hour call shift on technical and cognitive function, as well as the ability to learning a new skill.


      Thirty-one students trained to expert proficiency on a virtual reality part-task trainer. They then were randomized to either a control or sleep-deprived group. On the second testing day they were given a novel task. Fatigue was assessed using the Epworth Sleepiness Scale. The National Aeronautics and Space Administration–Task Load Index was used to assess cognitive capabilities.


      There was no difference between the control and sleep-deprived groups for performance or learning of surgical tasks. Subjectively, the Epworth Sleepiness Scale showed an increase in sleepiness. The National Aeronautics and Space Administration–Task Load Index showed an increase in total subjective mental workload for the sleep-deprived group.


      Sleep-deprived subjects were able to complete the tasks despite the increased workload, and were able to learn a new task proficiently, despite an increase in sleepiness.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Choy I.
        • Okrainec A.
        Simulation in surgery: perfecting the practice.
        Surg Clin North Am. 2010; 90: 457-473
        • Seymour N.E.
        • Gallagher A.G.
        • Roman S.A.
        • et al.
        Virtual reality training improves operating room performance: results of a randomized, double-blinded study.
        Ann Surg. 2002; 236: 458-464
        • Uchal M.
        • Tjugum J.
        • Martinsen E.
        • et al.
        The impact of sleep deprivation on product quality and procedure effectiveness in a laparoscopic physical simulator: a randomized controlled trial.
        Am J Surg. 2005; 189: 753-757
        • Jakubowicz D.M.
        • Price E.M.
        • Glassman H.J.
        • et al.
        Effects of a twenty-four hour call period on resident performance during simulated endoscopic sinus surgery in an accreditation council for graduate medical education-compliant training program.
        Laryngoscope. 2005; 115: 143-146
        • Lehmann K.S.
        • Martus P.
        • Little-Elk S.
        • et al.
        Impact of sleep deprivation on medium-term psychomotor and cognitive performance of surgeons: prospective crossover study with a virtual surgery simulator and psychometric tests.
        J Surg. 2010; 147: 246-254
        • Morris T.L.
        • Miller J.C.
        Electrooculographic and performances indices of fatigue during simulated flight.
        Biol Psychol. 1996; 42: 343-360
        • Roach G.D.
        • Dorrian J.
        • Fletcher A.
        • et al.
        Comparing the effects of fatigue and alcohol consumption on locomotive engineers' performance in a rail simulator.
        J Hum Ergol. 2001; 30: 125-130
        • Arnedt J.T.
        • Owens J.
        • Crouch M.
        • et al.
        Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion.
        JAMA. 2005; 294: 1025-1033
        • Murray D.
        • Dodds C.
        The effect of sleep disruption on performance of anaesthetists—a pilot study.
        Anaesthesia. 2003; 58: 520-525
        • Kahol K.
        • Leyba M.J.
        • Deka M.
        • et al.
        Effect of fatigue on psychomotor and cognitive skills.
        Am J Surg. 2008; 195: 195-204
        • Taffinder N.J.
        • McManus I.C.
        • Gul Y.
        • et al.
        Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator.
        Lancet. 1998; 352: 1191
        • Leff D.R.
        • Aggarwal R.
        • Rana M.
        • et al.
        Laparoscopic skills suffer on the first shift of sequential night shifts: program directors beware and residents prepare.
        Ann Surg. 2008; 247: 530-539
        • Hart S.G.
        • Staveland L.E.
        Development of NASA-TLX (task load index): results of empirical and theoretical research.
        in: Hancock P.A. Meshkati N. Human Mental Workload. North Holland Press, Amsterdam1988
        • Zheng B.
        • Cassera M.A.
        • Martinec D.V.
        • et al.
        Measuring mental workload during the performance of advanced laparoscopic tasks.
        Surg Endosc. 2010; 24: 45-50
        • Yurko Y.Y.
        • Scerbo M.W.
        • Prabhu A.S.
        • et al.
        Higher mental workload is associated with poorer laparoscopic performance as measured by the NASA-TLX tool.
        Sim Healthcare. 2010; 5: 267-271
        • Montero P.N.
        • Acker C.E.
        • Heniford B.T.
        • et al.
        Single incision laparoscopic surgery (SILS) is associated with poorer performance and increased surgeon workload compared with standard laparoscopy.
        Am Surg. 2011; 77: 73-77
        • Wadhera R.K.
        • Henrickson Parker S.H.
        • Burkhart H.M.
        • et al.
        Is the “sterile cockpit” concept applicable to cardiovascular surgery critical intervals or critical events?.
        J Thorac Cardiovasc Surg. 2010; 139: 312-319
        • Miró E.
        • Cano M.C.
        • Espinosa-Fernández L.
        • et al.
        Time estimation during prolonged sleep deprivation and its relation to activation measures.
        Hum Factors. 2003; 45: 148-159
        • Bohnen H.G.
        • Gaillard A.W.
        The effects of sleep loss in a combined tracking and time estimation task.
        Ergonomics. 1994; 37: 1021-1030
        • Maddox W.T.
        • Glass B.D.
        • Wolosin S.M.
        • et al.
        The effects of sleep deprivation on information-integration categorization performance.
        Sleep. 2009; 32: 1439-1448
        • Nurok M.
        • Czeisler C.A.
        • Lehmann L.S.
        Sleep deprivation, elective surgical procedures, and informed consent.
        N Engl J Med. 2010; 363: 2577-2579
        • Nasca T.J.
        • Day S.H.
        • Amis Jr, E.S.
        • et al.
        The new recommendations on duty hours from the ACGME task force.
        N Engl J Med. 2010; 363: e3
        • Johns N.J.
        A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale.
        Sleep. 1991; 14: 540-545
        • Pham T.
        • Roland L.
        • Benson K.A.
        • et al.
        Smart tutor: a pilot study of a novel adaptive simulation environment.
        Stud Health Technol Inform. 2005; 111: 385-389
        • Ganai S.
        • Donroe J.A.
        • St Louis M.R.
        • et al.
        Virtual-reality training improves angled telescope skills in novice laparoscopists.
        Am J Surg. 2007; 193: 260-265
        • Haluck R.S.
        • Gallagher A.G.
        • Satava R.M.
        • et al.
        Reliability and validity of Endotower, a virtual reality trainer for angled endoscope navigation.
        Stud Health Technol Inform. 2002; 85: 179-184
        • Hart S.G.
        NASA-Task Load Index (NASA-TLX); 20 Years Later.
        in: Proceedings of the Human Factors and Ergonomics Society 50th Annual Meeting HFES, Santa Monica2006: 904-908
        • Laird N.M.
        • Ware J.H.
        Random-effects models for longitudinal data.
        Biometrics. 1982; 38: 963-974
        • Samkoff J.S.
        • Jacques C.H.
        A review of studies concerning effects of sleep deprivation and fatigue on residents' performance.
        Acad Med. 1991; 66: 687-693