Uncovering patient safety considerations in laparoscopic cholecystectomy using cognitive task analysis

Introduction: Educating residents on laparoscopic operations requires direct teaching and deliberate practice. Attending surgeons are often systematic when performing surgery, which creates a challenge when instructing surgery residents. The aim of this study was to use cognitive task analysis to expand laparoscopic cholecystectomy into microsteps reflecting expert surgeon cognition (perceptions, assessments, decisions, etc.) throughout the operation such that these could be better formalized and conveyed to residents in educational materials or assessments and to attending surgeons as teaching scripts.

Materials and methods: One surgeon, a surgical resident, and a human factors specialist conducted cognitive task analyses with three expert general surgeons and one hepatobiliary surgeon using semi-structured interviews. These interviews expanded an existing task model of laparoscopic cholecystectomy to specifically add patient safety aspects including injury prevention, risk management, and complication detection for each step. Interview analysis resulted in an expanded task diagram.

Results: Cognitive task analysis expanded the current laparoscopic cholecystectomy task model from 19 to 97 microsteps. In addition to microsteps, an additional major step was identified, the planning step or step zero. Steps with the greatest number of microsteps included dissection with 15 microsteps and intraoperative cholangiogram with 10 microsteps.

Discussion: Laparoscopic cholecystectomies are complex operations with multiple microsteps. Identification of these steps can lead to explicit strategies that can improve training of surgeons, with an end towards efficacy and safety. The identification of a planning step prior to beginning the operation is a significant finding that should arguably be included in all future cognitive task analyses regardless of operation or procedure, to emphasize to trainees what senior surgeons have learned through experience. These findings inform the development of interventions for surgical training and evaluation of competency.