Study Environment
This controlled laboratory study was conducted at the Medical Simulation Center of West China Hospital of Sichuan University. The study protocol was approved by the University of West China Hospital of Sichuan University Research Ethics Board (2019 Approval No. 1071). Informed consent was obtained from all participants prior to data collection. Each participant provided written consent before entering the study.
Apparatus
The team performance was done on a laparoscopic training box (SL-PE480, Shinno-Med Inc., Shanghai, China. Figure 1). Three 5mm diameter endoscopic instruments were inserted through 3 ports to the surgical site. The surgical site was illuminated by a Stryker X8000 light source, captured by a 30-degree laparoscope, and displayed on a 26-inch high-definition monitor (CANON Legria H50FG, Tokyo, Japan). On the object transportation task, the operators used two 5mm curved graspers (Ethicon Endo-Surgery Inc., Cincinnati, Ohio, USA). On the suturing task, the operator used a pair of needle drivers (ET705R, Ethicon Endo-Surgery Inc., Cincinnati, Ohio, USA) to perform the suturing and was assisted by the assistant who used a 5mm curved grasper (Ethicon Endo-Surgery Inc., Cincinnati, Ohio, USA).
Participants
A total of 114 surgical residents who had no experience of simulated laparoscopic training in teams (88 men and 26 women aged 34.3 ± 4.8 years) were recruited from the Department of Surgery Residency Program at the West China Hospital of Sichuan University between May 2020 and October 2020. The hospital is a leading tertiary hospital in China with specialties in minimally invasive surgery. Most participants had at least four hours of individual laparoscopic training experience with a bench-top laparoscopic training box. Some of the participants had experience performing a complete laparoscopic procedure on a virtual model. The participants were randomized into 57 two-person teams. Table 1 shows the results of a custom-designed survey of the pre-training surgical clinical experience of participants [25]. We also assessed the participants' moods before operation with the Profile of Mood States (POMS) [26] and the Positive and Negative Affect Schedule (PANAS-SF) questionnaires [27].
Team Tasks
After the surveys, two random participants arrived at the simulation lab as a team (operator and assistant) and were asked to perform two laparoscopic tasks, object transportation and collaborative suturing. For the object transportation task, the assistant was required to move the 30-degree laparoscope appropriately in order to assist the operator in transporting an object (plastic cylinder, 2cm in diameter) between three pegs located at three different sides of a cardboard box (18 × 15 × 9 cm) inside the training box (Figure 1). It is essential for the assistant to understand the optical properties of the laparoscope and how to manipulate the scope to keep the object and instruments in the center of the field of view. The collaborative suturing task required the assistant to remove an obstacle (rubber band) placed on top of the surgical site so that the operator could perform a successful intracorporeal suture (Figure 1). During the task, the assistant must control the laparoscope to view the suture site, the suture needles, and the movements of a pair of needle drivers in the hands of the operator.
The two tasks included in this study address the required individual and team skills for performing a laparoscopic surgery. At the individual level, both participants must scan the surgical site, control the laparoscopy equipment, and develop eye-hand and bimanual coordination skills. At the team level, the tasks required the two team members to develop the ability to coordinate their movements and to communicate clearly with each other.[25]
Procedure
Each 2-person team was required to perform the two tasks under three different acoustic conditions. The order of the acoustic conditions were randomized to counterbalance possible learning effect in the practice. Each team was allowed a 10-minute break between acoustic conditions to minimize individual biases. Each participant in the team was required to wear headsets that delivered the acoustic condition and canceled out ambient sounds while the participant performed the tasks.
Measures
Task performance was recorded via a digital camera connected to the laparoscopic tower. Video analysis was later performed by one experienced surgeon, who was unaware of the study purposes. This surgeon examined the videos, labeled the starting and ending points of subtasks in each video, and counted the errors performed by the residents in each team. These measures were then used to generate a summative task score and a total score for the performance of each team.
Table 1. Task measures, subtask times, and errors that were used for the calculation of total task scores
Table 1
A list of time and error measures taken from two tasks and the description
| Object Transportation | Collaborative Suture |
| Measure | Description | Measure | Description |
Time | Total time | Object on to Peg C - Trial start | Total time | Suture cut - Trial start |
| Time on peg A | Object on to Peg A - Trial start | Time on preparation | Needle first puncture - Trial start |
| Time on peg B | Object on to Peg B - Object on to Peg A | Time on suturing | Beginning of 1st knot tying - Needle first puncture |
| Time on peg C | Object on to Peg C - Object on to Peg B | Time on knot 1 | Beginning of 2nd knot tying - Beginning of 1st knot tying |
| | | Time on knot 2 | Scissor in view - Beginning of 2nd knot tying |
| | | Time on cutting | Thread cut - Scissor in view |
Errors | # of object drop (+3 s) | number of plastic triangle drop during entire trial | # of needle adjustment | Number of needle being picked up, orientation adjustment |
| # of object transfer between hands (+3 s) | Number of object being transfer between hands of the chief operator | # of needle insert/exiting | Number of attempts of needle inserting and exiting the suture sides |
| # of incorrect view (+3 s) | number of object or tips of instrument out of the scope view | # of cutting | Number of attempts of cutting thread after knot typing |
| # of horizontal line twist (+3 s) | Number of times when the scope view is not horizontal. | # of incorrect view | number of object or tips of instrument out of the scope view |
| # of instruments collision (+3 s) | Number of collision between scope and instruments | # of horizontal line twist | Number of times when the scope view is not horizontal. |
| Communication | Silent team (+10s), insufficient communication (+5 s) | # of instruments collision | Number of collision between scope and instruments |
| | | Communication | Silent team (+10s), insufficient communication (+5 s) |
| | | Quality of knot tying | Loose knot (+10 s); unsecured knot (+5 s) |
Table 1 lists the times for completing each task, subtask, and the number of errors for each of the two tasks, and provides a detailed description of each of the measures. The times of each task were calculated by subtracting the completion time with the start time of the task. A penalty (three seconds) was added to the task time for each error observed.
The recorded errors were further divided into individual and team errors. For example, dropping an object and dropping the needle when adjusting position were considered individual errors, whereas misalignment of laparoscope, collision of instruments, and miscommunications were considered as team errors. A secure knot received a zero penalty, a slipping knot received a 10-second penalty, and a knot received a 20-second penalty, as based on Derossis’ scoring system for suture quality [28].
A total score for an operation was obtained by adding the penalty times to the time taken to complete the task. To adjust the total score of each task so that it was comparable to the other task, we normalized the total score of each task to the maximum value recorded during the task, using the equations below:
Normalized object transportation score = (Maximum – total score of trial)/Maximum × 100
Normalized suturing score = (Maximum – total score of teach trial)/Maximum× 100
Normalized task score = (Normalized object transportation score + Normalized suturing score) / 2
The total team score was averaged by taking two team members' transportation and suturing scores.
Team score = (Normalized individual score 1 + Normalized individual score 2) / 2
The more accurately and quickly a task was completed by each team member, the higher the individual and team scores were.
Post-test assessment on team quality
At the end of each operation, the participants of each team were required to evaluate their team performance in terms of quality of interpersonal communication and cooperation. Each team member used a 10-point scale (1 the worst and 10 the best) to answer eight questions. A mean quality score was determined from the sum of the two self-rated scores from each of the two team members.
Statistical Analysis
The study sample size (number of teams) was determined according to a similar investigation. In 2020, Yang et al. reported the effect of different emotions on laparoscopic performance. [16] They asked surgeons-in-training to perform simulated surgical tasks on the Lap Mentor (Simbionix, Tel Aviv, Israel) immediately after watching three movies that evoked different emotions. Surgeons with positive emotions performed a task within a significantly shorter time (13.7 ± 2.5 minutes) than those with negative (18.5 ± 3.8 minutes) and neutral emotions (17.7 ± 3.9 minutes), for approximately 35% differences between the positive-and-negative-emotion groups. We anticipated a modest 20% improvement in our study, since the impact on the performance of a surgical team might not be as strong as the impact on an individual of a team. Using a one-way analysis of variance (ANOVA) model with a two-tailed alpha of 0.05 and a beta of 0.10 (power of 90%), we calculated a minimum of 18 teams needed in each of acoustic conditions to demonstrate significance. We eventually recruited 57 teams to test our hypothesis with SPSS Statistics 22.0 (IBM Corporate, Armonk, New York, USA). Variables such as task times and penalties were compared between the three acoustic conditions by one-way within-subject ANOVA. Post-hoc pairwise comparisons were performed by the Bonferroni method. Pearson’s r (correlation coefficient) was calculated to examine the correlation between the team experience score and the surgical performance score. Data were reported as means ± standard deviations. p < 0.05 was considered statistically significant.