Highlights
- •Preoperative priming improves technical skill and performance in junior residents.
- •Senior residents reported higher self-efficacy scores following preoperative priming.
- •Generic and specific skills in open procedures improved following priming.
Abstract
Background
Preoperative warm-up regimens are increasingly utilised in the surgical field, however no consensus on benefits of priming across surgical experience has been realised. The aim of this study was to evaluate the impact of simulation preoperative priming on operative performance across levels of resident experience.
Methods
A single-blinded randomised control trial was carried out in a regional surgical training centre. Volunteers were randomised to undergo simulated surgical warm-up procedure prior to their first case as primary operator or proceed directly to surgery.
Results
Performances of 147 operative procedures were collected over an 18 month period, experience ranging from PGY2-PGY 7. Senior participants consistently outperformed junior residents in unprimed operative cases (p = 0.005). In primed operative performances no significant difference in aggregate performance scores was found (p = 0.07).
Conclusion
Priming confers a greater advantage to junior residents with particular regard to generic surgical skills. Senior residents demonstrate improved self-efficacy scores measured following priming.
Keywords
1. Introduction
Preoperative warm-up regimens are increasingly recognised in the surgical field. Postulated to hone mental focus,
1
bimanual control,2
dexterity3
; numerous methods of preoperative preparation exist, including team-based practice,4
individual rehearsal- Gabbott B.
- Tennent D.
- Snelgrove H.
Effect of mental rehearsal on team performance and non-technical skills in surgical teams: systematic review.
BJS Open. Oct 31 2020; https://doi.org/10.1002/bjs5.50343
5
while focusing on non-technical,4
technical,- Gabbott B.
- Tennent D.
- Snelgrove H.
Effect of mental rehearsal on team performance and non-technical skills in surgical teams: systematic review.
BJS Open. Oct 31 2020; https://doi.org/10.1002/bjs5.50343
6
or both skill sets.- Moldovanu R.
- Târcoveanu E.
- Dimofte G.
- Lupaşcu C.
- Bradea C.
Preoperative warm-up using a virtual reality simulator.
J Soc Laparoendosc Surg. 2011 Oct-Dec 2011; 15: 533-538https://doi.org/10.4293/108680811X13176785204409
7
Warm-up procedures to date have focused on laparoscopic and endoscopic procedures,
8
,9
with the use of warm-up procedures in other surgical approaches sparse in the literature.10
Indeed, the use of simulation in open procedures to confer a transferability of skill to surgeons from the simulation to the operating room is relatively unknown.- Deuchler S.
- Wagner C.
- Singh P.
- et al.
Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
PLoS One. 2016; 11e0150690https://doi.org/10.1371/journal.pone.0150690
11
Similarly, existing literature has focused on the use of preoperative priming in the assessment of performance within a single procedure,7
,10
,- Deuchler S.
- Wagner C.
- Singh P.
- et al.
Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
PLoS One. 2016; 11e0150690https://doi.org/10.1371/journal.pone.0150690
12
limiting generalisability of findings.The efficacy of surgical priming regimens across levels of experience also remains under debate.
13
Despite a heterogenous cohort of participants included in studies to date including medical students,2
residents,14
and specialists,6
no consensus on benefits of priming across surgical experience has been realised. The potential of differing benefits to be garnered from priming across levels of experience, is under evaluated in the literature.- Moldovanu R.
- Târcoveanu E.
- Dimofte G.
- Lupaşcu C.
- Bradea C.
Preoperative warm-up using a virtual reality simulator.
J Soc Laparoendosc Surg. 2011 Oct-Dec 2011; 15: 533-538https://doi.org/10.4293/108680811X13176785204409
James et al. expounded on the Improved Surgical training Initiatives in Irish and UK training which have seen a paradigm shift in the structure and curriculum in surgical specialty training.
15
The transfer to a competency-based program with the introduction of core surgical training posts prior to specialty allocations through competitive processes is well documented.16
Following allocation of specialty training posts, surgical trainees are required to gather sufficient breadth of knowledge in experience in their specialty of choice to ensure a level of a day-1 consultant is achieved at the time of completion of residency.15
Incorporated into this are core competencies required to be completed by trainees, with real-time and intraoperative oversight and assessment provided by the supervising consultant surgeon. With proficiency in surgical cases a core aim of surgical specialty training, methods to decrease time taken to achieve proficiency in technical skill acquisition are paramount. The aim of this study was to evaluate the impact of priming across level of experience in open procedures in both trauma and elective cases.2. Material and methods
2.1 Study design
A single-blinded randomised control trial was conducted in a regional training centre following institutional board approval. Inclusion criteria consisting of non-consultant hospital doctors undergoing orthopaedic rotations available for the defined study period with sufficient experience to complete orthopaedic procedures as primary operators was applied. Volunteers not fulfilling these inclusion criteria were excluded from participation in the study. Informed consent was obtained from eligible participants prior to recruitment into the study. Data was collected over 18 months across three 6-monthly rotations, encompassing the length of resident rotations rostered with consultant supervisors within the unit consisting of both dedicated trauma and elective lists.
Computer generated block randomisation was applied to participant-allocated shifts across trauma and elective theatres; each participant was randomised to perform a case as primary operator having completed a virtual reality module in the preoperative period immediately before proceeding to the operating room or proceed directly to surgery without having completed a virtual reality warm-up.
2.2 Simulation-based preoperative priming
The aim of preoperative priming was to adequately prepare participants for theatre through improvement of physical and mental synaptic responses. Weller et al.
8
discusses the use of specific components of a procedure to incur an improved reaction and response time. Precision OS (Vancouver, Canada) simulation curriculum contains both specific and generic tasks within Orthopaedic surgery. The simulator is comprised of one portable headset and two wireless handheld controllers. Bimanual control and variable degrees of haptic feedback is available in the handheld devices to provide greater operative feedback during module completion. Modules aim to mirror a real world theatre environment consisting of patient positioning, surgical approaches, and guides users on the appropriate use of instruments through stages of procedures which have demonstrated validity in the literature.11
,17
Use of generic skills and specific skills related to the nature of the operative procedure were used, including the use of intraoperative fluoroscopy to guide plate and screw insertion in trauma cases, and the use of arthroscopic modules to guide portal entry, bimanual control, and depth perception.Preoperative priming was conducted by participants for 5–10 min or until completion of the module. Virtual Reality surgical modules were selected by the researchers to provide simulated practice in generic surgical skills required intraoperatively. Simulated surgical procedures were carried out within the theatre environment to facilitate practice of preoperative priming into the surgical day.
2.3 Assessment
Subjective surgical performance assessments of the first operative case of the day completed by participants were completed by participating expert surgical consultants blinded to the priming status of participants. Participants were assessed on case in which they were the primary operator, having performed more than 75% of the procedure, in keeping with international surgical training guidelines on procedure-based assessment including exposure, and intraoperative technique congruent with global ratings scales used in this study.
16
,18
Assessors were recruited within the department of surgery, all experts and recognised trainers based in national surgical training curricula, with considerable experience in assessment, provision of feedback, and guidance of surgical residents rotating through the department. Previous working experiences between assessors and residents were not evaluated as part of this study. The study design mirrored current surgical training curricula structures closely, in which trainees may rotate several times through a regional unit. A validated Global Rating Scale (GRS)19
was used to assess participant performance, analysing operative performance across seven components including respect for tissue, time and motion, instrument handling, knowledge of instruments, flow of operation, use of assistants, knowledge of procedure, and an aggregate score of overall performance. This provided a numeric assessment of operative performance on a Likert 1–5-point scale, with a total aggregate of between 7 and 35 applied to each operative performance.2.4 Operative procedures
Consensus on difficulty level of trainee-appropriate operative procedures was achieved. Experts within the national surgical training committee were asked using a 1–5 scale rate the degree of difficulty of surgical procedures, based on individual step complexity within the procedure; potential risk of damage to surrounding structures; level of invasiveness of procedure; degree of expected blood loss, and risk to patient independent of anaesthesia
20
(Table 1).Table 1Procedure type by complexity.
| Level of Surgical Complexity | Type of operative Procedure | Number of procedures | Level of experience |
|---|---|---|---|
| 1 | Removal of metal, Carpal Tunnel Release, excision soft tissue tumour | 23 | ST:10 |
| JT: 12 | |||
| 2 | Knee arthroscopy, Distal Radius ORIF, TA Rupture repair | 50 | ST: 35 |
| JT:15 | |||
| 3 | Ankle ORIF, Supracondylar fracture fixation, Shoulder arthroscopy | 34 | ST: 14 |
| JT: 20 | |||
| 4 | Hip Fracture management: proximal femoral nail, hemiarthroplasty, Dynamic Hip Screw | 24 | ST: 19 |
| JT: 5 | |||
| 5 | Total Hip Replacement, Total Knee Replacement, Revision Surgery, open fracture fixation | 15 | ST: 15 |
| JT: 1 |
Appendix: ST: Senior Trainee, JT: Junior Trainee.
Operative cases with significant patient factors which would increase case complexity, or those which would require significant consultant surgeon input were excluded from the study. This included haemodynamically unstable patients; those with an American Society of Anaesthesiologists (ASA) of greater than III; patients with a BMI >40, or patients with challenging anatomy determined on preoperative imaging. Cases in which the supervising consultant was required to give guidance or take over the case were also excluded from analysis.
2.5 Participant feedback
Participants were asked to rate their performance on a Likert-scale 1–7 following completion of the procedure, outlining perceived self-efficacy and confidence in their abilities in the preoperative, intraoperative, and postoperative period.
2.6 Participant characteristics
Baseline demographics including sex, experience as primary operator and previous experience with virtual reality were also collected. Level of experience was categorised as Junior if Postgraduate Year (PGY)1–4, and Senior if PGY 5–8. Number of operative cases in both trauma and elective settings were also collected.
2.7 Study powering
Statistical powering using Multivariate analysis of variance of effects and interaction using the outlined study design was calculated. A partial eta-squared value of 0.16 from a hypothesised moderate effect size seen between primed and unprimed arms of the study was used. A total number of three predictors and eleven response variables in accordance with the study design was also applied. A significance of 0.05 and a B powering of 0.80 was used, demonstrating a required sample size of 106, calculated using Software G*Power 3.1.9.7. To account for time constraints within operative theatre due to the nature of the environment, an attrition rate of 30% was applied, yielding a total required sample size of 138.
2.8 Statistical analysis
Collected data was pseudo-anonymised on collection and stored on a local server before being coded for data analysis. Statistical analysis was conducted using the IBM SPSS software (IBM Inc). Descriptive statistics were expressed as mean ± SD.
Multivariate analysis of variance was used to evaluate the impact of level of difficulty, level of experience of the participant, and priming status on subscale and aggregate scores of participants. Similarly, feedback given by participants following completion of a procedure as primary operator was evaluated to identify the impact of procedure type and participant level of experience on self-reported performance in both primed and unprimed arms. Box's test of equality of Covariance was used to assess equality of covariance matrices. In cases where departures from homogeneity were identified using a value of p = 0.01 as significant, Pillai's trace was used to account for heterogeneity of variance-covariance matrices. A difference in between-subject and within-subject findings was considered statistically significant if p < 0.05.
3. Results
Performance from a total of 147 operative procedures across ten trainees were collected over an 18-month period. Trainee experience ranged from PGY 2-PGY 7. Procedures in both primed and unprimed arms were collected, with a total of 54 primed, and 93 unprimed. A significant interaction across level of experience and level of case complexity was noted in several performative parameters. Flow of operation (p = 0.04), knowledge of procedure (p = 0.02) in the unprimed arm was highlighted, with aggregate scores in the unprimed arm just failing to reach significance (p = 0.055).
3.1 Impact of level of experience on performance
A statistically significant difference across level of experience in respondent variables was demonstrated (p = 0.01). Between-subject metrics similarly demonstrated a statistically significant difference in subjective metrics across levels of experience in the unprimed arm in both subscale and aggregate scores (Table 2). Senior participants performed significantly better than junior participants with an aggregate score of 29.07 ± 3.86 vs. 24.71 ± 5.86 (p = 0.005). However, performance following preoperative priming resulted in no significant difference between Senior and Junior participants across several subscale metrics, with no significant difference in aggregate scores on performance (30.78 ± 4.83 vs. 30.18 ± 5.11; p = 0.07).
Table 2Subjective assessment scores across primed and unprimed arms.
| Subcale measurements | Priming status | Senior | Junior | Significance |
|---|---|---|---|---|
| Respect for tissue | Primed | 4.52 0.64 | 4.35 0.70 | p = 0.06 |
| Unprimed | 4.26 0.65 | 3.59 1.0 | p = 0.01 | |
| Time and Motion | Primed | 4.37 0.79 | 4.18 0.88 | p = 0.04 |
| Unprimed | 4.07 0.82 | 3.47 1.23 | p = 0.11 | |
| Instrument Handling | Primed | 4.33 0.83 | 4.12 0.99 | p = 0.01 |
| Unprimed | 4.04 0.58 | 3.53 1.06 | p = 0.11 | |
| Knowledge of Instruments | Primed | 4.44 0.75 | 4.35 0.70 | p = 0.49 |
| Unprimed | 4.41 0.57 | 3.65 0.93 | p = 0.01 | |
| Flow of operation | Primed | 4.41 0.88 | 4.24 0.75 | p = 0.07 |
| Unprimed | 4.15 0.60 | 3.35 0.93 | p = 0.003 | |
| Use of assistants | Primed | 4.33 1.0 | 4.35 0.78 | p = 0.26 |
| Unprimed | 4.00 0.83 | 3.71 0.77 | p = 0.01 | |
| Knowledge of procedure | Primed | 4.37 0.68 | 4.24 0.75 | p = 0.09 |
| Unprimed | 4.22 0.64 | 3.47 0.87 | p = 0.002 | |
| Total | Primed | 30.78 4.83 | 30.18 5.11 | p = 0.07 |
| Unprimed | 29.07 3.86 | 24.71 5.86 | p = 0.005 |
Means assessment of subscale and aggregate scores was conducted to evaluate the effect size of level of experience on performative metrics. This demonstrated measures of association across aggregate scores in the unprimed arm as 0.13, indicating 13% of variance in performance occurring as a result of experience in theatre. However, in the primed arm, 5% of variance in performance calculated through partial eta squared estimates was attributable to level of experience of participants.
3.2 Impact of level of experience on self-efficacy scores
Participants were asked to provide feedback on perceived confidence in the preoperative, intraoperative, and postoperative period on their confidence as primary operator in the procedure. No significant difference in self-efficacy scores were demonstrated across levels of experience in the unprimed arm (Table 3). However senior participants demonstrated a statistically significant difference in perceived performance both intraoperatively (p = 0.003) and postoperatively (p = 0.002) following primed procedures compared to junior residents despite no significant difference in aggregate score performance noted between levels of experience.
Table 3Self-efficacy scores across the perioperative period.
| Senior | Junior | Significance | ||
|---|---|---|---|---|
| Confidence Preoperatively | Primed | 5.89 0.80 | 5.71 0.58 | p = 0.88 |
| Unprimed | 5.70 0.95 | 5.76 0.56 | p = 0.38 | |
| Confidence Intraoperatively | Primed | 5.85 0.90 | 5.29 1.04 | p = 0.003 |
| Unprimed | 5.48 1.45 | 4.82 1.59 | p = 0.22 | |
| Confidence Postoperatively | Primed | 5.96 0.89 | 5.25 1.03 | p = 0.002 |
| Unprimed | 5.52 1.34 | 4.65 1.90 | p = 0.25 |
3.3 Impact of level of difficulty on performance
Level of difficulty was associated with a statistically significant difference in performance parameters and self-efficacy metrics (p = 0.03). In procedures conducted in the unprimed arm, a statistically significant decrement in performance was demonstrable across increased case complexity within flow of operation (p = 0.01), use of assistants (p = 0.001), knowledge of procedure (p = 0.01), and cumulative scores (p = 0.02).
Similarly, across primed arms a statistically significant difference in performance remained across handling of instruments (p = 0.001), knowledge of instruments (p = 0.04), knowledge of procedure (p = 0.02), and cumulative scores (p = 0.006). While a significant difference in performance across levels of difficulty remained in the primed arm, the aggregate scores achieved with increased case complexity remained significantly higher in the primed group.
Means testing from increased case complexity cases were assessed across both primed and unprimed arms. In the unprimed arm increased level of difficulty was associated with a significant difference in mean aggregate scores (31.59 vs. 26.80; p = 0.01). In the primed group, a decrement in performance was also noted across difficulty level (32.20 vs. 28.43) however this failed to reach significance (p = 0.10).
3.4 Level of difficulty across self-efficacy scores
No significant difference in self-efficacy markers across the preoperative (p = 0.99), intraoperative, (p = 0.33) or postoperative period (p = 0.39) in the unprimed arm was noted. Similarly, no significant difference across any level of case complexity was noted in the primed arm in preoperative (p = 0.83), intraoperative (p = 0.16), or postoperative (p = 0.26) periods.
3.5 Baseline characteristics
A total of ten residents were included for analysis, with one trainee in PGY2, two in PGY 3, two in PGY 4, one in PGY 5, three in PGY 6, and one in PGY 7. Four residents were female, with six males included for analysis. No significant difference in performance or self-efficacy scores was noted across gender.
4. Discussion
Use of preoperative priming has been an area of interest in recent years, with methods including mental imagery,
8
box trainers,21
and high fidelity simulators10
used to prepare surgeons for theatre. Despite this, heterogeneity in the literature to date on the impact of simulation training across level of experience remains. Kroft et al.- Deuchler S.
- Wagner C.
- Singh P.
- et al.
Clinical efficacy of simulated vitreoretinal surgery to prepare surgeons for the upcoming intervention in the operating room.
PLoS One. 2016; 11e0150690https://doi.org/10.1371/journal.pone.0150690
22
highlighted limitations of warm-up routines in junior trainees, finding a significant improvement in primed procedures was demonstrable only with senior residents. In contrast, Chen et al.21
demonstrated a ubiquitous improvement across all levels of experience. Improvement in operative performance following the use of preoperative priming in this study was found to have a statistically significant association with level of experience. While both Junior and Senior level participants were found to improve following preoperative priming, junior level participants yielded a demonstrable improvement such that no significant difference was found across several subscale and aggregate scores in the primed arm.The difference in effect size of level of experience on performance across primed and unprimed scores is notable. With a larger magnitude of improvement demonstrable across junior residents, small improvements found across senior resident performance may be reflective of the ceiling effect recognised in many assessment tools,
23
and a plateau effect seen with increasing operative experience.24
The use of a GRS within priming studies has been demonstrated to identify improvement in expert surgeons,6
with generic surgical skills continuing to differentiate between levels of senior experience.- Moldovanu R.
- Târcoveanu E.
- Dimofte G.
- Lupaşcu C.
- Bradea C.
Preoperative warm-up using a virtual reality simulator.
J Soc Laparoendosc Surg. 2011 Oct-Dec 2011; 15: 533-538https://doi.org/10.4293/108680811X13176785204409
24
In this study in procedures of increasing case complexity, senior participants continued to demonstrate superior skills across flow of operation (p = 0.04), and knowledge of procedure (p = 0.02), in keeping with competency-based surgical training. Authors have hypothesised that preoperative priming impacted performance of tasks of less complex procedures which precluded skill differentiation. Thus, an additional advantage of a surgical warm-up is conferred to junior residents in procedures with lower difficulty ratings.The use of metrics to evaluate specific skills in operative performance has been highlighted in the literature,
1
with limitations of cumulative scores recognised. While the cumulative score in priming arms in this study remained significantly dependent on level of difficulty (p = 0.006), evaluation of subscale scores demonstrates a difference in the nature of skills demonstrated with increasing case complexity. Following preoperative priming, a statistically significant difference in knowledge of instruments (p = 0.01) and knowledge of procedure (p = 0.02) across level of procedure difficulty was noted, perhaps reflective of the predominantly generic simulation-based preoperative preparation. Thus, while no improvement across level of difficulty is demonstrated following preoperative priming, sub analysis highlights potential deficits in the priming protocol which failed to account for procedure specific task analysis.Senior participants demonstrated a statistically higher level of confidence in self-efficacy scores in both intraoperative (p = 0.003) and postoperative (p = 0.002) periods following primed procedures. Lees et al.
25
discussed the impact of internal and external factors on confidence of surgical residents, reporting the influence of internal factors including personal expectations, self-perception, and the development of individual skill as significant in impacting both training and confidence levels. Senior level residency was also associated with higher levels of confidence, reflected by Bucholz et al.,26
who reported lower PGY training associated with a lower confidence level in operative skill. This study mirrors these findings in the primed arm, with no significant difference in confidence levels noted in the unprimed arm. Authors hypothesise greater operative experience in senior residents enabled greater insight regarding personal expectations in theatre. This resulted in improved performance in primed procedures which was reflected in the higher level of confidence demonstrated by these participants in the postoperative period.Limitations to this study exist. This is a single-centre study, which limits generalisability of findings. However, this study was conducted over a period of 18 months with participants rotating through as part of a national training program, with residents as such representative of the training body. Assessors were not blinded to the participant performing the procedure; the study was designed to mimic archetypical methods of surgical trainee assessment carried out in current competency based curricula, and is thus beholden to the same biases contained within national training structures. This study was undertaken during the COVID pandemic with a significant impact on operative lists, and resident training. While the impact of this on these results cannot be quantified, it is important conclusions drawn from these findings are characterised in relation to the context from which they were drawn.
5. Conclusion
The use of preparatory tools in the preoperative period are increasingly recognised. Simulation-based procedural tasks to date have been demonstrated to confer benefits in laparoscopic and endoscopic procedures, with this study highlighting the potential use of simulation to preoperatively primed surgeons in open operations. While preoperative priming appears to confer a greater advantage to junior residents with particular regard to generic surgical skills, senior residents reported improved self-efficacy scores measured from procedures completed in a primed state. This highlights the potential spectrum of benefits derived from use of preoperative priming across levels of experience. Future studies should evaluate the use of mixed method preoperative warm up across generic and specific skills in open procedures to improve operative performance.
Funding
No funding
Financial disclosure
No grants or financial support was received for this work.
Declaration of competing interest
This is a conflict of interest statement pertaining to the submission of the manuscript “Preoperative priming results in improved operative performance with less experienced surgeons”.
We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us.
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Article info
Publication history
Published online: November 28, 2022
Accepted:
November 27,
2022
Received in revised form:
November 15,
2022
Received:
May 23,
2022
Publication stage
In Press Journal Pre-ProofIdentification
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© 2022 The Authors. Published by Elsevier Inc.
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