First, Do No Harm: Expertise and Metacognition in Laparoscopic Surgery

摘要

Minimally invasive surgery is a double-edged sword presenting both advantages anddangers to a patient. On the one hand, damage to healthy tissue is reduced and recovery periods are shorter. On the other hand, the surgeon is handicapped by degraded perceptual information so that the probability of certain types of errors is increased (e.g., cutting or damaging the common bile duct during laparoscopic cholecystectomy). In challenging cases surgeons continually assess whether the patient's best interest might be served by converting a laparoscopic case to an open-incision one. Converting widens the scope and quality of perceptual information available, providing hands and eyes with direct access to the operative area. This research focuses on surgical decision making in the context of the decision to convert. A cognitive task analysis effort, involving field observations and a research study, was undertaken to elicit information about decisions made during surgery. Ten experienced (staff) and ten senior resident surgeons were shown videotape from a difficult laparoscopic surgery case. The surgeons responded to structured questions at critical points in the procedure and also provided running commentary as the operation unfolded. Based on their observations, approximately half of the surgeons decided that the case should be converted to an open procedure at some point during the operation. The verbal protocols were analyzed to identify differences as a function of expertise (staff vs. resident) and of the conversion decision (opener vs. nonopener). Staff surgeons made significantly more inferences and predictions from perceptual information and expressed awareness of boundary conditions to safe operation more frequently than resident surgeons interviewed. Further, there was evidence for a lack of situation awareness for the residents who chose not to open.