title: Intra-operative disruptions, surgeon's mental workload, and technical performance in a full-scale simulated procedure.
abstract: OBJECTIVE
  Surgical flow disruptions occur frequently and jeopardize perioperative care and surgical performance. So far, insights into subjective and cognitive implications of intra-operative disruptions for surgeons and inherent consequences for performance are inconsistent. This study aimed to investigate the effect of surgical flow disruption on surgeon's intra-operative workload and technical performance.
  
  
  METHODS
  In a full-scale OR simulation, 19 surgeons were randomly allocated to either of the two disruption scenarios (telephone call vs. patient discomfort). Using a mixed virtual reality simulator with a computerized, high-fidelity mannequin, all surgeons were trained in performing a vertebroplasty procedure and subsequently performed such a procedure under experimental conditions. Standardized measures on subjective workload and technical performance (trocar positioning deviation from expert-defined standard, number, and duration of X-ray acquisitions) were collected.
  
  
  RESULTS
  Intra-operative workload during simulated disruption scenarios was significantly higher compared to training sessions (p < .01). Surgeons in the telephone call scenario experienced significantly more distraction compared to their colleagues in the patient discomfort scenario (p < .05). However, workload tended to be increased in surgeons who coped with distractions due to patient discomfort. Technical performance was not significantly different between both disruption scenarios. We found a significant association between surgeons' intra-operative workload and technical performance such that surgeons with increased mental workload tended to perform worse (β = .55, p = .04).
  
  
  CONCLUSIONS
  Surgical flow disruptions affect surgeons' intra-operative workload. Increased mental workload was associated with inferior technical performance. Our simulation-based findings emphasize the need to establish smooth surgical flow which is characterized by a low level of process deviations and disruptions.
authors.affiliation: Institute and Outpatient Clinic for Occupational, Social, and Environmental Medicine, Ludwig-Maximilians-University Munich, Ziemssenstrasse 1, 80336, Munich, Germany. matthias.weigl@med.lmu.de.
authors.forename: Matthias
authors.initials: M
authors.lastname: Weigl
authors.affiliation: Computed Aided Medical Procedures (CAMP), Computer Science Department (I-16), Technical University of Munich, Munich, Germany.
authors.forename: Philipp
authors.initials: P
authors.lastname: Stefan
authors.affiliation: Imaging Research Laboratories, Robarts Research Institute, The University of Western Ontario, London, Canada.
authors.forename: Kamyar
authors.initials: K
authors.lastname: Abhari
authors.affiliation: Computed Aided Medical Procedures (CAMP), Computer Science Department (I-16), Technical University of Munich, Munich, Germany.
authors.forename: Patrick
authors.initials: P
authors.lastname: Wucherer
authors.affiliation: Computed Aided Medical Procedures (CAMP), Computer Science Department (I-16), Technical University of Munich, Munich, Germany.
authors.forename: Pascal
authors.initials: P
authors.lastname: Fallavollita
authors.affiliation: Institute for Emergency Medicine and Management in Medicine (INM), Ludwig-Maximilians-University Munich, Munich, Germany.
authors.forename: Marc
authors.initials: M
authors.lastname: Lazarovici
authors.affiliation: Department of Trauma Surgery, Ludwig-Maximilians-University Munich, Munich, Germany.
authors.forename: Simon
authors.initials: S
authors.lastname: Weidert
authors.affiliation: Department of Trauma Surgery, Ludwig-Maximilians-University Munich, Munich, Germany.
authors.forename: Ekkehard
authors.initials: E
authors.lastname: Euler
authors.affiliation: Surgical Safety and Human Factors Research, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: Ken
authors.initials: K
authors.lastname: Catchpole
mesh_terms: D001288:Attention; D002983:Clinical Competence; D003198:Computer Simulation; D005260:Female; D006801:Humans; D008297:Male; D008348:Manikins; D066231:Surgeons / Q000523:psychology*; D014584:User-Computer Interface; D054854:Vertebroplasty; D057188:Workflow; D016526:Workload / Q000523:psychology*
keywords: Flow disruption; Performance; Simulation; Stress; Surgery; Workload