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Introduction: Obtaining the critical view of safety (CVS) is considered an important step to reduce bile duct injuries during laparoscopic cholecystectomy (LC). However, existing literature suggests that few surgeons obtain adequate CVS when LC videos are directly evaluated by experts. This discrepancy calls for effective, standardized CVS teaching methods. While self-assessment (SA) remains the principal tool utilized by practicing surgeons for performance improvement, its effectiveness is controversial. The aim of this study was to compare surgeon SAs of repeated LC performance and attainment of the CVS with that of expert raters., Methods: Multi-institutional study of surgeon members from the Society of American Gastrointestinal and Endoscopic Surgeons who volunteered to participate. All surgeons were asked to submit an LC video and complete a SA of the CVS quality using the Strasberg scale (0-6 score with ≥5 score indicating appropriate CVS). The same videos were reviewed by two blinded expert raters, members of the Society of American Gastrointestinal and Endoscopic Surgeons safe cholecystectomy task force, who had received prior rater training. Surgeon self-ratings and expert ratings were compared with a Wilcoxon signed-rank test., Results: Twenty-five surgeon-participants were recruited, 13 of whom submitted an LC video. Surgeons did not achieve adequate CVS in their first submitted video based on expert ratings. Surgeons in the SA group overestimated their performance across all four scales: Operative Performance Rating System (z = -0.36, P = 0.715), Global Operative Assessment of Laparoscopic Skills (z = -0.37, P = 0.712), Strasberg (z = -1.84, P = 0.066), and Competency Assessment Tool (z = -0.73, P = 0.465). Surgeons in the coaching group overestimated their performance on each scale as well: Operative Performance Rating System (z = -0.67, P = 0.500), Global Operative Assessment of Laparoscopic Skills (z = -1.48, P = 0.138), Strasberg (z = -1.07, P = 0.285), and Competency Assessment Tool (z = -1.21, P = 0.225)., Conclusions: Our study confirms that an adequate CVS is infrequently obtained during LC in a small but national sample of general surgeons. It further adds to the existing body of literature that suggests that SA alone may be inadequate for performance improvement. Effective teaching methods such as expert or artificial intelligence coaching are needed to improve the use of appropriate CVS by surgeons that may help decrease bile duct injury risk., (Copyright © 2024. Published by Elsevier Inc.)

Emotional regulation is increasingly gaining acceptance as a means to improve well-being, performance, and leadership across high-stakes professions, representing innovation in thinking within the field of surgical education. As one part of a broader cognitive skill set that can be trained and honed, emotional regulation has a strong evidence base in high-stress, high-performance fields. Nevertheless, even as Program Directors and surgical educators have become increasingly aware of this data, with emerging evidence in the surgical education literature supporting efficacy, hurdles to sustainable implementation exist. In this white paper, we present evidence supporting the value of emotional regulation training in surgery and share case studies in order to illustrate practical steps for the development, adaptation, and implementation of emotional regulation curricula in three key developmental contexts: basic cognitive skills training, technical skills acquisition and performance, and preparation for independence. We focus on the practical aspects of each case to elucidate the challenges and opportunities of introducing and adopting a curricular innovation into surgical education. We propose an integrated curriculum consisting of all three applied contexts for emotional regulation skills and advocate for the dissemination of such a longitudinal curriculum on a national level., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Mental skills and emotional regulation training are gaining acceptance in surgical education as vital elements of surgeon development. These skills can effectively enhance technical skill development, improve well-being, and promote career longevity. There is evidence emerging in the surgical education literature to support the incorporation of mental skills and emotional regulation training curricula in residency training. In this study, we present the existing evidence supporting the use of this training with high performers to reduce stress and optimize well-being and performance. We also consider the recent research emerging in surgical education that offers validity evidence for use of mental skills training with surgeons. Finally, we provide a framework to guide the incorporation of these skills throughout the career of a surgeon and suggest methods to promote the development of mental skills training efforts nationally., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Surgery is very cognitively demanding, particularly for novices. Novices are required to direct full attention on the procedure at hand, and additional demands can lead to cognitive overload. Through extensive practice, experts develop spare attentional capacity (SAC) for simultaneous tasks. However, little effort has been made to enhance novices' SAC. Mental skills may enhance attention management and increase SAC. The purpose of this study was to determine the efficacy of a novel mental skills curriculum (MSC) to enhance novices' attention management., Methods: Sixty novice volunteers were randomly stratified to a control or MSC group based on baseline laparoscopic skill and mental skill use (assessed with the Test of Performance Strategies version 2 [TOPS-2]). All participants received laparoscopic training, whereas the MSC group received additional mental skills training. At all sessions, participants completed a secondary task during laparoscopy, which assessed SAC. Participants also completed the D2 Test of Attention and the TOPS-2 attention control subscale, which are valid attention measures., Results: Fifty-five novices completed the study. Both groups displayed significantly improved laparoscopic suturing ability (P < 0.001) and D2 performance (control: P < 0.005, MSC: P < 0.01), but there were no between-group differences in D2 or TOPS attention control scores. However, only the MSC group displayed significantly improved hit rate on the secondary task (P < 0.05)., Conclusions: The novel MSC implemented in this study enhanced surgical novices' SAC compared to controls, and it is clear that this curriculum may be effective at enhancing learners' ability to attend multiple task-relevant stimuli concurrently. Additional study of the impact of this MSC on learners' attentional capacity is currently underway., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Stress has been shown to negatively impact surgical performance, and surgical novices are particularly susceptible to its effects. Mental skills are psychological strategies designed to enhance performance and reduce the impact of stress to consistently facilitate the ideal mental conditions that enable performers to perform their best. Mental skills have been used routinely in other high-stress domains (e.g., with Navy SEALs, military pilots, elite athletes, and so forth) to facilitate optimal performance in challenging situations. We have developed a novel mental skills curriculum (MSC) to aid surgical trainees in optimizing their performance under stressful conditions. The purpose of this study was to determine the effectiveness of this MSC in reducing novices' stress., Methods: The MSC was implemented with a convenience sample of surgical novices over 8 wk. Two stress tests were administered before and after completion of the MSC to assess its effectiveness in reducing trainee stress. The Trier Social Stress Test (TSST) is a validated method of measuring participants' stress responses; it was implemented by giving participants 10 min to prepare for an impromptu presentation and 5 min to present it in front of a medical education expert who would be assessing them. The O'Connor Tweezer Dexterity Test (OTDT) is a test of fine motor dexterity; participants competed against each other in small groups who would complete the test the fastest. Such competition has been shown to cause acute stress in performers. To assess stress, heart rate (HR), perceived stress (STAI-6), and perceived workload (NASA-TLX) were completed during all testing sessions., Results: Nine novices (age 23 ± 7 y, 55% women) completed the MSC. HR increased significantly from resting to performance during the TSST and from early during competition (at 2 min and 30 s of elapsed time) to immediately after completing the task. However, participants perceived less stress during and immediately after the TSST and OTDT tests (P < 0.05) after completion of the MSC. In addition, they reported significantly less workload during the second OTDT administration (P < 0.05) and showed a trend toward faster completion of this test., Conclusions: The novel MSC was effective at reducing surgical novices' perceived stress and workload during two comprehensive stress tests. Although not statistically significant, participant's enhanced performance during the OTDT is encouraging. This curriculum may be valuable to help inexperienced learners reduce stress in a variety of situations related to learning and performing surgical skills. Additional research using a larger sample size is currently underway to validate the effectiveness of this curriculum., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Gallbladder perforation is difficult to diagnose and is associated with significant morbidity. This study investigates factors affecting outcome in patients with gallbladder perforation over two decades., Materials and Methods: From 1982 to 2002 data from patients undergoing cholecystectomy at one institution were prospectively collected. Patients treated for gallbladder perforation and gangrenous cholecystitis were identified and outcomes were compared. The chi(2) test, Student's t-test, and Mann-Whitney rank sum test were used for statistical analysis., Results: Two hundred eight of 11,360 patients who underwent cholecystectomy were diagnosed with gangrenous cholecystitis and 30 were diagnosed with gallbladder perforation. The perforation was contained in 9 and free in 21 patients. The diagnosis of gallbladder perforation was made preoperatively in 3% of patients. Men outnumbered women and Hispanics outnumbered Caucasians. Compared to patients with gangrenous cholecystitis, patients with gallbladder perforation presented at an older age (53 versus 60 years; P < 0.05), had more cardiovascular comorbidity (29% versus 50%; P < 0.05) and postoperative complications (19% versus 37%; P < 0.05), and required more ICU admissions (9% versus 33%; P < 0.001) and longer hospital stays (8 versus 13 days; P < 0.001). Early cholecystectomy within 24 h improved outcome (P < 0.05)., Conclusions: Gallbladder perforation is a rare complication of cholelithiasis that occurs more often in men, Hispanics, and older patients. It is rarely diagnosed preoperatively. Late operative intervention is associated with increased morbidity, mortality, number of ICU admissions, and long postoperative hospital stays. An early cholecystectomy strategy may lead to improved outcomes but may be difficult to implement and may not be cost-effective.