title: Taxonomy of instructions given to residents in laparoscopic cholecystectomy.
abstract: BACKGROUND
  Although simulation-based training allows residents to become proficient in surgical skills outside the OR, residents still depend on senior surgeons' guidance in transferring skills accumulated from simulators into the operating room. This study aimed to identify and classify explicit instructions made by attending surgeons to their residents during laparoscopic surgery. Through these instructions, we examined the role gaze guidance plays in OR-based training.
  
  
  METHODS
  A total of ten laparoscopic cholecystectomy cases being performed by PGY4 residents were analyzed. The explicit directional instructions given by the mentoring attending surgeons to their residents were identified and classified into four categories based on their locations in the coordinate system. These categories were further combined into two classes, based on the target of instructions. The frequencies of instructions in the two classes were compared, and effect size was calculated.
  
  
  RESULTS
  There were 1984 instructions identified in the ten cases. The instructions were categorized into instrument guidance (38.51%) and gaze guidance (61.49%). The instrument guidance focused on moving the instruments to perform surgical tasks, including directions to targets, instrument manipulation, and instrument interaction. The gaze guidance focused on achieving common ground during the operation, including target identification and target fixation. The frequency of gaze guidance is significantly higher than instrument guidance in a laparoscopic cholecystectomy (p < 0.001) with a large effect size (r = 0.6).
  
  
  CONCLUSIONS
  Gaze guidance has become the main focus of OR-based training. The results show a tight connection between adopting expert gaze and performing surgical tasks and suggest that gaze training should be integrated into the simulation training.
authors.affiliation: Department of Information Systems, University of Maryland, Baltimore County, Baltimore, MD, USA. fengy1@umbc.edu.
authors.forename: Yuanyuan
authors.initials: Y
authors.lastname: Feng
authors.affiliation: Department of Information Systems, University of Maryland, Baltimore County, Baltimore, MD, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Wong
authors.affiliation: Department of Surgery, Anna Arundel Medical Center, Annapolis, MD, USA.
authors.forename: Adrian
authors.initials: A
authors.lastname: Park
authors.affiliation: Department of Information Systems, University of Maryland, Baltimore County, Baltimore, MD, USA.
authors.forename: Helena
authors.initials: H
authors.lastname: Mentis
mesh_terms: D017081:Cholecystectomy, Laparoscopic / Q000193:education* / Q000295:instrumentation / Q000379:methods; D006801:Humans; D007396:Internship and Residency / Q000379:methods*; D007400:Interprofessional Relations; D009511:New England; D009633:Nonverbal Communication; D013663:Teaching / Q000379:methods* / Q000706:statistics & numerical data; D014705:Verbal Behavior; D014741:Video Recording
keywords: Gaze training; Instrument guidance; OR-based training; Simulation-based training; Surgical training