See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/320230518

Toward a Model of Human Information Processing for Decision-Making and

Skill Acquisition in Laparoscopic Colorectal Surgery

Article  in  Journal of Surgical Education · October 2017

DOI: 10.1016/j.jsurg.2017.09.010

CITATIONS READS

8 9,082

5 authors, including:

Eoin J. White Muireann Mcmahon

University of Limerick University of Limerick
16 PUBLICATIONS   35 CITATIONS    44 PUBLICATIONS   208 CITATIONS   

SEE PROFILE SEE PROFILE

Michael T Walsh John Calvin Coffey

University of Limerick University of Limerick
207 PUBLICATIONS   3,152 CITATIONS    513 PUBLICATIONS   7,842 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Design education View project

Axosuit - Assistive exoskeleton suitable for elderly persons View project

All content following this page was uploaded by Leonard O'Sullivan on 02 January 2018.

The user has requested enhancement of the downloaded file.

ORIGINAL REPORTS

Toward a Model of Human

Information Processing for
Decision-Making and Skill Acquisition
in Laparoscopic Colorectal Surgery
Eoin J. White, PhD,* Muireann McMahon, PhD,* Michael T. Walsh, PhD,†,‡,§
J. Calvin Coffey, PhD, FRCS,‡,║,¶ and Leonard O′Sullivan, PhD*,‡

*
School of Design, University of Limerick, Castletroy, Co. Limerick, Ireland; †School of Engineering, University
of Limerick, Castletroy, Co. Limerick, Ireland; ‡Health Research Institute, University of Limerick, Castletroy,
Co. Limerick, Ireland; §Bernal Institute, University of Limerick, Castletroy, Co. Limerick, Ireland; ║Graduate
Entry Medical School, University of Limerick, Castletroy, Co. Limerick, Ireland; and ¶Department of Colorectal
Surgery, University Hospital Limerick, University of Limerick, Castletroy, Co. Limerick, Ireland

OBJECTIVE: To create a human information–processing CONCLUSIONS: Surgical decision-making during laparo-

model for laparoscopic surgery based on already established scopic surgery is the result of a highly complex series of
literature and primary research to enhance laparoscopic processes influenced not only by the operator’s knowledge,
surgical education in this context. but also patient anatomy and interaction with the surgical
team. Newer developments in simulation-based education
DESIGN: We reviewed the literature for information-
must focus on the theoretically supported elements and
processing models most relevant to laparoscopic surgery.
events that underpin skill acquisition and affect the cogni-
Our review highlighted the necessity for a model that
tive abilities of novice surgeons. The proposed human
accounts for dynamic environments, perception, allocation
information–processing model builds on established liter-
of attention resources between the actions of both hands of
ature regarding information processing, accounting for a
an operator, and skill acquisition and retention. The results
dynamic environment of laparoscopic surgery. This revised
of the literature review were augmented through intra-
model may be used as a foundation for a model describing
operative observations of 7 colorectal surgical procedures,
robotic surgery. ( J Surg Ed ]:]]]-]]]. J
C 2017 Association of
supported by laparoscopic video analysis of 12 colorectal
Program Directors in Surgery. Published by Elsevier Inc. All
procedures.
rights reserved.)
RESULTS: The Wickens human information-processing
KEY WORDS: human information processing, surgical
model was selected as the most relevant theoretical model
education, decision-making, laparoscopic surgery, medical
to which we make adaptions for this specific application.
device design
We expanded the perception subsystem of the model to
involve all aspects of perception during laparoscopic surgery. COMPETENCIES: System based practice, practice based
We extended the decision-making system to include learning and improvement, medical knowledge
dynamic decision-making to account for case/patient-
specific and surgeon-specific deviations. The response
subsystem now includes dual-task performance and non-
technical skills, such as intraoperative communication. The
INTRODUCTION
memory subsystem is expanded to include skill acquisition Laparoscopic surgery has become a popular approach for
and retention. several procedures previously performed openly.1-3 The
operator coordinates their eyes, hands, and an elongated
surgical instrument in a skillful manner, as well as inter-
Funding: This work was supported by the Irish Research Council under the
IRCSET Scholarship Scheme.
preting a 2-dimensional environment on a screen to visual-
Corresponence: Leonard O’Sullivan, PhD, University of Limerick, F2–022 Foundation ize the anatomy.4 Furthermore, they are removed from
Building, Castletroy, Co. Limerick, Ireland; e-mail: leonard.osullivan@ul.ie direct contact with the tissues, so their tactile feedback

Journal of Surgical Education
& 2017 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 1
Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2017.09.010
is fundamentally different from that experienced during
open surgery. Common laparoscopic colorectal surgery
procedures include appendectomy, sigmoid colectomy,
anterior resection, and total mesocolic excision.5-8
Laparoscopic surgery has many proven benefits over open
procedures, with reduced risk of infection,9 reduced
surgical invasiveness, shorter recovery times,10 reduced or
invisible scars,11 and lower morbidity and mortality in many
common procedures.12 Laparoscopic colorectal techniques
have also been shown to reduce mortality rates.13,14
Contextual information is important for learning and skill
acquisition. In this regard, identifying stimuli, selecting
an appropriate response, and improving memory have an
effect on a surgeon’s ability to perform surgery.15 Training
skilful and competent surgeons is required to ensure
high-quality care and reduce the risk of adverse events.
Surgical education plays an important role in the
acquisition of surgical skills. However, traditional models
by which surgeons are trained have been challenged
owing to rapid advances in technology, higher focus on
patient-safety, and an overall need for a value-driven health
system.16
The practice of surgery is becoming increasingly more
complex. Evolving surgical education methods should
appreciate information processing as, although modern
technologies provide tools to offer environments for resi-
dents to learn and understand to a greater degree than that
offered to previous generations, surgical educators need to
use both innovation and technology to make the best use of
data and knowledge to train novice surgeons.17 Grierson15
states that, while clinical skills are often practiced in chaotic
clinical environments, many of the same skills are also
regularly carried out under stress-free conditions. Both
chaotic and stress-free environments are equally realistic,
with the chaotic environment adding a degree of difficulty,
more so than realism. Therefore, the different environ-
mental conditions may affect the amount that finite
cognitive resources are taxed.
Highly contextual, information rich, or affect-inducing
learning environments work to increase the complexity of
skill practice.15 Therefore, newer developments in simula-
tion-based education where operating room (OR) accuracy
is paramount must focus on, not only the physical aspects of
surgery but also the theoretically supported elements and
events that underpin skill acquisition and affect the cogni-
tive abilities of the surgical trainee. Research has shown that
surgical information processing is affected by knowledge,
expertise, awareness,18 distraction,19 and mental resour-
ces.20 However, there are few data available on informa-
tion-processing models that unify the different information-
processing models detailed in the literature. The aim of the
present study was to develop a Human Information and
Processing (HIP) model for skill acquisition and decision-
making in the context of surgical education, based on a
review of the literature and primary research in the OR.
2 Journal of Surgical Education
Volume ]/Number ]
] 2017
MATERIALS AND METHODS
Literature Review and Selection of Primary
Model
The literature was reviewed for information-processing
models which could be applied to laparoscopic surgery.
The short-listed models identified from our search were the
Multiple Resource Theory by Wickens (2002), the 2-step
model of intraoperative decision-making proposed by Flin
et al. (2007), the 3-loop model of decision-making pro-
posed by Harvey and Fischer (2005), the naturalistic model
of intraoperative decision-making proposed by Cristancho
et al. (2013), and the Wickens model of Human Informa-
tion Processing (HIP).21
The Multiple Resource Theory model describes resources as
being parallel, separate, or relatively independent when being used.
The model contains 4 dimensions that account for the variances
in time-shared performance: stages, perceptual modalities, visual
channels, and processing codes. Each of the 4 dimensions contains
separate levels of visual and auditory input.22
The 2-step model of intraoperative decision-making is based
on situation assessment and decision-making. The model
proposes 4 types of decision-making: intuitive, which is used
most often by expert operators; rule-based, in which operators
follow a set procedure to complete a surgical task; analytical,
which requires the operator to simultaneously compare a
number of possible courses of actions and their outcomes in
order to decide on the most suited path; and creative decision-
making, which is rarely applied to surgery.23
The 3-loop model accounts for changes in a skilled
person’s estimate of the probability of successful perform-
ance of a task. An inner loop describes how short-term
memory is used by all factors needed to make a decision.
A secondary, slow cognitive loop, shows how task feedback
is further refined and assimilated into a mental model of the
task, supporting the inner loop. The outer loop conveys
storage of mental models for all previous tasks.24
The naturalistic model of intraoperative decision-making
focuses on 3 major and sometimes overlapping components:
situation assessment, reconciliation cycle, and gaining
information. The proposed reconciliation cycle refers to
the continuous, iterative process of gaining and processing
information, and anticipating future events. The naturalistic
model is more focused on design-making during nonroutine
challenges rather than an entire surgical procedure. How-
ever, it further substantiated the need for situation assess-
ment and intuitive decision-making to be included in our
HIP model.25
Based on our review of the above models, including their
previous applications to surgical domains, we selected and
advanced the Wickens HIP (Fig. 1), which describes informa-
tion flow between cognitive subsystems, as indicated by the
arrows. The Wickens HIP model was previously applied to
describe information processing in other high-stress

FIGURE 1. Wickens model of human information processing.21
environments, including aviation,26 and has been used as the
basis for information processing during endoscopic surgery.27
However, the model proposed by Grimbergen et al. (2004) is a
direct adaption of the Wickens model and was not modified to
take into account the work of other research in the literature as
applied specifically to that type of surgery.
This model is based on continual sensing of stimuli or
events by the sensory system. They are interpreted based on
memory of past experience (perceived), in this case, previous
laparoscopic surgeries and education related to anatomy and
procedure methodology. Once the situation is understood
through perception and cognition, an action or response is
triggered. Anything that is perceived can then be responded
to directly. Many mental operations are not performed
automatically. They require the selective application
of limited processing resources. Attention represents
this selective supply of mental resources.28 Feedback is
important for establishing that the intended goal is achieved.
Feedback indicates that actions can be directly sensed
through interactions with the environment. This flow of
information can be initiated at any point. In situations where
the flow of information is continuous, action can cause
perception and vice versa. Cognitive operations generally
require more time, attention, or mental effort than percep-
tion, which is the distinct difference between them. However,
both have similar implications on action.
Primary Research
Intraoperative Observations
Laparoscopic procedures were observed to gain a greater
understanding of how operators make decisions in the OR,
and the extent to which external stimuli influence decision-
making. Seven colorectal surgeries were observed, including
laparoscopic anterior resection, left hemicolectomy, small
bowel resection, cholecystectomy, ileocolic anastomosis,
abdominal perineal resection, and Delorme’s procedure.
Laparoscopic Video Study
Laparoscope video recordings of 12 procedures were studied
to determine patterns of surgical actions.
Journal of Surgical Education
Volume ]/Number ]
] 2017
The videos analysed were of laparoscopic appendectomies
(n ¼ 4), laparoscopic sigmoid colectomies (n ¼ 3), anterior
resection (n ¼ 1), and total mesocolic excisions (n ¼ 4).
The key findings drawn from surgical observations and video
analyses were the use of intraoperative communication and
teamwork and the ability of the operator to filter relevant and
nonrelevant inputs during surgery. The main operator-dele-
gated tasks to surgical assistants were to reorient the laparo-
scopic, or hold an instrument in place while they used other
instruments. Intraoperative communication, task delegation,
and input filtering were incorporated into the revised model.
RESULTS
Model Outline in Brief
The 4 primary systems of (1) perception, (2) decision-making,
(3) response and (4) memory, as detailed in the original
Wickens model, were expanded to encompass environmental,
information-processing, and perceptual factors, which are
important in laparoscopic surgery. These subsystems are based
on findings from subsystem-specific human information mod-
els, surgical observations, and analysis of laparoscopic surgery
video data. The model serves as a base for understanding the
factors that influence decision-making, and the allotment of
operators’ attention resources, enhancing our understanding of
how operators decide which course of action to take. The
system of attention resources remained unchanged. The modi-
fied model is separated into 5 subsystems: (1) perception,
(2) attention resources, (3) decision-making, (4) response, and
(5) memory. Each subsystem of this HIP model can be used to
enhance surgical education in these areas and to illustrate the
inherent strengths and weaknesses of laparoscopic surgeons,
from novice to expert (Fig. 2).
1. Perception: We revised this subsystem to include 3 ele-
ments of surgical perception, i.e., visual/spatial, tactile/
haptic, and limb localization feedback. We also incorpo-
rated an input-filtering component.
2. Attention resources: This system is unchanged; however, it
now feeds into the added situation awareness, situation
assessment, and self-assessment component of the deci-
sion-making subsystem.
3. Decision-making: We added a new component to this
subsystem that includes situation awareness, situation
assessment, and self-assessment. We included dynamic
decision-making and expanded it to include the 4 types
of decision-making from the 2-step model: creative, rule-
based, analytical, and intuitive.
4. Response: We incorporated dual-task performance and motor
control, and a component, which balances the attention
resources allocated to both limbs. Intraoperative communi-
cation and task delegation were added from primary research.
5. Memory: Skill acquisition and reinforcement were added,
which draw from and add to working memory and long-
term memory.
3
 FIGURE 2. Human information processing model for laparoscopic surgery.
Perception
In laparoscopic surgery, perception primarily applies to 3
main areas: visual/spatial, tactile and haptic feedback, and
limb localization feedback.
Visual-Spatial Perception
Recognition of anatomy is a fundamental surgical skill,
which is acquired with experience. The operator must also
use bloodless planes during surgery, such as when mobiliz-
ing the colon and mesocolon during colectomy. These
tissue planes tend to be avascular, so adherence to the planes
is preferable to avoid intraoperative bleeding.29
Tactile/Haptic Perception
Haptic perception (or haptics) is the combination of tactile
perception and kinesthetic perception.39 Tactile perception
is the perception of pressure, vibration, and texture.
Kinesthesia, the sensitivity of movement of the muscles, is
gained from body movements of anything that requires
precise control over the position and movement of body
parts, whether self-generated or externally imposed.30,31
There are 2 schools of thought on the role of haptics in
laparoscopic surgery. On one hand, it is reported that haptic
feedback is reduced or removed when performing laparo-
scopic surgery, and is not relied on to direct surgery. Others
suggest that haptic feedback is still a factor of intraoperative
technical outcome as operators use the feeling of forces and
pressures encountered by the instruments to help inform
their interactions with soft tissues.32 The color and texture
of soft tissues convey important anatomical information,
4 Journal of Surgical Education
Volume ]/Number ]
] 2017
and haptic feedback complements visual feedback when
identifying obscure tissue planes and blood vessels as well as
abnormal tissues.33
Limb Localization Perception
The operator judges the position of their limbs relative
to the laparoscopic instruments, as perceived through
the laparoscope. Surgical dexterity has been widely
acknowledged as an important attribute of surgical skill
acquisition.34
Inputs Filtering. The authors suggest that an operator
must identify and differentiate relevant inputs from
irrelevant inputs during surgery. Mental capacity remains
surgeon-specific; however, the ability to differentiate inputs
increases during skill acquisition. An expert operator would
possess a greater capacity for filtering inputs than a novice
operator.
Attention/Mental Resources
People have finite cognitive capacities. This is represented in
human information–processing models in the form of a
pool of limited resources, which are drawn on, as necessary,
to meet cognitive demands. Under specific circumstances,
surgical issues may be the result of an operator’s lapse in
performance if an adverse event occurs, or if rapid decisions
are not made adequately, owing to inadequate monitoring,
predicting, and planning.35 The authors suggest that, most
of the time, operators encounter surgical issues when they
find themselves in unanticipated situations where they lack
the intuitive thinking required to resolve it, as their
decision-making has a flawed anatomic basis. Full attention
is initially required to achieve the desired outcome of a goal,
or to execute actions or strategies.
Controlled processing is beneficial at this stage as task
execution is still flexible, but its taxation of cognitive
resources makes it slow to execute and presents difficulty
when combining controlled processing with other cogni-
tively demanding tasks. This is also the case for combining
both performance and learning.36,37 As the amount of
information to be processed increases, the availability of
mental resources decreases.15 Any information processing
that occurs which is unrelated to skill, such as environ-
mental distractions, or the trainee’s own thoughts, arousal,
anxiety, or focus, can impede a surgeon’s learning process.38
Decision-Making
The decision-making system was expanded to encompass
the different decision-making processes associated with a
dynamic environment of laparoscopic surgery. Four separate
decision-making processes are illustrated in the model,
which are adapted from the 2-step model of intraoperative
decision-making: creative, rule-based, analytical, and
intuitive.23
The decision-making subsystem also includes situation
awareness, situation assessment, and self-assessment compo-
nents, as when more information becomes apparent to the
operator, different skillsets may need to be used. Situation
awareness is the core characteristic of decision-making when
combined with intuitive decision-making. For example,
when the operator cannot find the correct anatomical
landmarks to follow during a procedure, they must explore
in a controlled manner until they find them. The authors
propose that this concept of directed and focused anatom-
ical exploration is an important aspect of situation awareness
for operators.
It is interesting that, according to this model, current
decision-making processes are well-likened to current lapa-
roscopic surgical information processing, with only a slight
deviation in decision-making and perception. Skill acquis-
ition, retention, and reinforcement are constantly occurring
from novice to expert surgeons. However, the means by
which surgeons make decisions differ between novice and
expert. Novice surgeons, although well educated, follow the
rule-based approach. This approach relies on the surgeon’s
knowledge of surgical literature to perform prescribed
procedures. As surgeons become more educated, there is a
shift from rule-based to intuitive decision-making, whereby
the surgeon can instinctually perform procedures efficiently.
Surgical educational practices could be altered to address
these deficiencies, or otherwise acknowledge them, by
placing more emphasis on intuitive decision-making from
the onset, rather than having it naturally occur.
Journal of Surgical Education
Volume ]/Number ]
] 2017
Memory
Working Memory
Working memory is an important component for holding,
manipulating, and processing information.39 It is the
mental system used to temporarily store and process new
and previously stored information, and delegates perceived
stimuli to the areas of the brain responsible for action.
Therefore, working memory is necessary for staying focused
on a task, and requires the use of attention resources.
According to Brady et al.,40 working memory does not have
a fixed capacity; instead, its capacity is dependent on exactly
what is being remembered.
Long-Term Memory
Long-term memory is the relatively permanent memory
storage system of the brain of unknown capacity. After
information proceeds through working memory, it can be
permanently stored for retrieval when needed. When tasks
are performed repeatedly following consistent steps, or
when several instances of a single task are stored in long-
term memory, repetition becomes faster and more consis-
tent. The need to follow a prescribed process decreases, and
performing the same actions requires less effort. During this
process of automisation, capacity for concurrent actions
increases. However, the ability to deviate from task perform-
ance is lessened.37 For laparoscopic surgery, Gallagher
et al.41 showed that each surgical skill (psychomotor
performance, spatial judgment, operative judgment, deci-
sion-making, comprehending instruction, and learning)
requires less attention resources as a laparoscopic surgeon
gains more experience in practicing them.
Skill Acquisition and Reinforcement
Cognitive architecture consists of a limited-capacity working
memory and virtually unlimited long-term memory.42 It is
suggested that capacity limitations of short-term and work-
ing memory determine the amount learned from complet-
ing a task.
We included skill acquisition and reinforcement in the
model to reflect training and skill retention required for
laparoscopic surgery. Progression through the assessment of
theoretical knowledge and operative skills is required to
reach the level of expertise that an operator requires.
Procedural skills vary from one surgical procedure to
another, the combinations of which define the surgical
craft.43 Skill acquisition is an important component of
laparoscopic surgery and is an important part of retention
and decay.
It has been shown by Proteau et al. (1994) that, during
motor skill training, frequent changing of the training task
improves learning outcomes. The introduction of more
variability in laparoscopic training tasks would lead to a
better learning experience. This is known as the contextual
interference effect, in which variable conditions of practice
5
during a set time impairs performance in skill acquisition,
but improves performance in delayed retention tests, when
compared with practicing the same task repeatedly for the
same set time.44
After training practices, trainees can try to recall images
and sensations collected while performing skill tasks,
and create vivid mental images of the execution of the
task. Mental imagery can be associative or dissociative,
as it can be viewed from first person or third person
perspectives.36
Response
The response subsystem is expanded upon the original
Wickens HIP model. In our response system, we introduce
dual-task performance. Response execution is split into 2
paths: dominant hand actions and nondominant hand
actions. This representation of surgical response is impor-
tant for surgical education as both limbs perform separate
actions, with the dominant hand providing detailed actions
and the nondominant hand providing support. Feedback is
also essential for learning.16
Dual-Task Performance
Dual-task performance was a new element introduced to the
response subsystem. Dual-task performance affects quality
of intraoperative technical outcome. Laparoscopic surgery
requires both dominant and nondominant hand use for
skilled actions and instrument manipulation, and surgical
competency in relation to dual-task conditions differs with
experience.45 Stefanidis et al.46 note a decrement in
secondary task performance under dual-task conditions
across all levels of experience; however, the secondary task
introduced was visual-spatial and was modeled on a task for
assessing attention.
Motor Control
Smith et al.47 indicated that motor skill performance is most
often measured by time and accuracy, taking into account
errors. Torkington et al.48 theorised the possibility that
there are significant differences in the way new motor skills
are learned between the dominant and nondominant hands,
which are why both motor skill components are kept
separate in the proposed model. In laparoscopic surgery,
the nondominant hand performs support actions to aid the
dominant hand.
In relation to motor control, mental resources are
distributed evenly between both the dominant and non-
dominant hand. However, if more resources are needed for
primary task performance, unused mental resources can be
exchanged between primary and secondary tasks to ensure
that the surgical procedure is completed efficiently. This can
happen rapidly, depending on the tasks undertaken. The
amount of resources required, as well as the attention
capacity of the operator, is more limited in novice surgeons
6 Journal of Surgical Education
Volume ]/Number ]
] 2017
than experts. Implicit motor learning during surgical train-
ing has the potential to promote neural efficiency.49 In
addition, repetitive practice also leads to muscle memory,
which facilitates motor and technical competence while
performing surgical procedures.50
Intraoperative Communication and Task Delegation
Intraoperative teamwork and communication has an
effect on nontechnical skills and technical performance,
and affects operative duration. Specifically, surgical,
anesthetic, and nursing teamwork skills affect technical
outcome of surgery. It has been shown that levels
of team skills in OR teams correlate with the frequency
of technical errors and problems occurring during
operations.51
Task delegation, along with other nontechnical skills such
as intraoperative communication, is the direct result of
communication, teamwork, and activity coordination
within the operating theater. Rapid task delegation can
occur in a dynamic environment if an adverse event should
occur, or if a surgery requires rapid task switching to ensure
a positive technical outcome.52 In extreme circumstances,
dynamic task delegation may occur to prevent adverse
events from having a negative clinical outcome. The rapid
and repeated delegation of tasks from the operator to team
members, as well as the withdrawal of other tasks from other
members, has been found to enhance teams’ ability to
perform more reliably while also allowing skill acquisition
and reinforcement.53
Limitations of the HIP Model
The main limitations of this study include the recruitment
of 1 surgeon and 1 observer at the primary research stage.
However, we purposely focused on a single experienced
surgeon to build a laparoscopic HIP model rather than a
generalized model that applies to the entire surgical pop-
ulation. The model also purposely omits shared mental
models, which are prevalent in the literature, as we focused
on the information processing of the primary surgeon only.
A further limitation of this work is determining how to
empirically test the model to validate its components and
structure. A process of review and refinement is needed to
further develop and substantiate the model in order to aid
innovation in laparoscopic surgery. Despite these limita-
tions, this model addresses the need for a HIP model,
which encompasses all aspects of laparoscopic surgery
from stimuli filtering through response and intraoperative
communication.
Further work is required to develop a valid taxonomy of
individual operators’ decision-making processes and skillsets
for further feedback so that the model may be applied
across a broader array of laparoscopic surgeries beyond the
colorectal region.
CONCLUSIONS
The revised model of laparoscopic surgeon information
processing builds on existing theories of information proc-
essing, and describes how surgical actions and decisions are
processed, and how skills are acquired and refined with
experience. The model is derived from primary research
such as observation of surgeons’ intraoperative behaviors.
Our study adds to the existing literature by providing a
model that characterizes the cognitive processes used by
laparoscopic surgeons when assessing intraoperative stimuli
and deciding on a response approach. This model also
elaborates on surgical response through incorporation of
dual-task performance and skill acquisition and retention
through augmentation of the memory system. Although the
OR is set up in a particular way so that all instruments are
readily accessible, there is no guarantee that the operator
will encounter an ideal environment intraoperatively. The
operator’s ability to filter these stimuli is an important factor
for obtaining the ideal technical outcome of the procedure
when nonroutine challenges occur.
If surgical education is not examined in the context of
information processing, there is a risk that surgical skills
training and surgical simulators may be designed in a way
that they do not reflect the way operators make decisions
and learn skills. Moreover, there may be a risk that these
surgical representations contain extraneous components that
may impede skill acquisition. Although robotics surgery is
now mature, studies of surgical skills training and education
for robotics surgery continue to evolve. The proposed HIP
model may also be applicable to robotics skills acquisition as
well.
REFERENCES
1. Bozkurt M, Unsal M, Kapan S, et al. Is laparoscopic
appendectomy going to be standard procedure for
acute appendicitis; a 5-year single center experience
with 1,788 patients. Eur J Trauma Emerg Surg. 2015;
41(1):87-89.
2. Guida F, Clemente M, Valvano L, Napolitano C.
Laparoscopic or open hemicolectomy for elderly
patients with right colon cancer? A retrospective
analysis G Chir. 2015;36(5):205.
3. Nomi T, Fuks D, Agrawal A, Kawaguchi Y, Ogiso S,
Gayet B. Totally laparoscopic right hepatectomy com-
bined with resection of the inferior vena cava by anterior
approach. Ann Surg Oncol. 2015;22(3) 851-851.
4. Cuschieri A. Visual displays and visual perception in
minimal access surgery. Surg Innov. 1995;2(3):209-214.
5. Kwag S-J, Kim J-G, Oh S-T, Kang W-K. Single
incision vs conventional laparoscopic anterior resection
Journal of Surgical Education
Volume ]/Number ]
] 2017
for sigmoid colon cancer: a case-matched study. Am J
Surg. 2013;206(3):320-325.
6. Vasilakis V, Clark CE, Liasis L, Papaconstantinou HT.
Noncosmetic benefits of single-incision laparo-
scopic sigmoid colectomy for diverticular disease: a
case-matched comparison with multiport laparoscopic
technique. J Surg Res. 2013;180(2):201-207.
7. Elmore U, Fumagalli Romario U, Vignali A,
Sosa MF, Angiolini MR, Rosati R. Laparo-
scopic anterior resection with transanal total
mesorectal excision for rectal cancer: preliminary
experience and impact on postoperative bowel
function. J Laparoendosc Adv Surg Tech. 2015;25(5):
364-369.
8. Jaschinski T, Mosch C, Eikermann M, Neugebauer EA.
Laparoscopic versus open appendectomy in patients
with suspected appendicitis: a systematic review of
meta-analyses of randomised controlled trials. BMC
Gastroenterol. 2015;15(1):48.
9. Kiran RP, El-Gazzaz GH, Vogel JD, Remzi FH.
Laparoscopic approach significantly reduces surgical
site infections after colorectal surgery: data from
national surgical quality improvement program. J Am
Coll Surg. 2010;211(2):232-238.
10. Trastulli S, Cirocchi R, Listorti C, et al. Laparoscopic
vs open resection for rectal cancer: a meta‐analysis of
randomized clinical trials. Colorectal Dis. 2012;14(6):
e277-e296.
11. Leroy J, Barry BD, Melani A, Mutter D, Marescaux J.
No-scar transanal total mesorectal excision: the last
step to pure NOTES for colorectal surgery. JAMA
Surg. 2013;148(3):226-230.
12. Lee J, Mabardy A, Kermani R, Lopez M, Pecquex N,
McCluney A. Laparoscopic vs open ventral hernia
repair in the era of obesity. JAMA Surg. 2013;148
(8):723-726.
13. Antoniou SA, Antoniou GA, Koch OO, Pointner R,
Granderath F-A. Laparoscopic colorectal surgery con-
fers lower mortality in the elderly: a systematic review
and meta-analysis of 66,483 patients. Surg Endosc.
2015;29(2):322-333.
14. Gietelink L, Wouters MW, Bemelman WA, et al.
Reduced 30-Day Mortality After Laparoscopic Color-
ectal Cancer Surgery: A Population Based Study From
the Dutch Surgical Colorectal Audit (DSCA). Ann
Surg. 2016;264(1):135-140.
15. Grierson LEM. Information processing, specificity of
practice, and the transfer of learning: considerations for
reconsidering fidelity. Adv Health Sci Educ. 2014;
19(2):281-289.
7
16. Vedula SS, Ishii M, Hager GD. Objective assessment
of surgical technical skill and competency in the
operating room. Annu Rev Biomed Eng. 2016;19:
301-325.
17. Neumeister MW. Technology and education: the
future of plastic surgery training. Plast Reconstr Surg
Glob Open. 2016;4(6):e777.
18. Cristancho SM, Apramian T, Vanstone M, et al.
Thinking like an expert: surgical decision making as
a cyclical process of being aware. Am J Surg. 2016;
211(1):64-69.
19. Harrison Y, Horne JA. The impact of sleep deprivation
on decision making: a review. J Exp Psychol Appl.
2000;6(3):236.
20. Gallagher AG, Satava RM, O’Sullivan GC. Attentional
capacity: an essential aspect of surgeon performance.
Ann Surg. 2015;261(3):e60-e61.
21. Wickens CD, Hollands JG, Banbury S, Parasuraman
R. Engineering Psychology & Human Performance.
London: Psychology Press; 2015.
22. Wickens CD. Multiple resources and performance
prediction. Theor Issues Ergon Sci. 2002;3(2):
159-177.
23. Flin R, Youngson G, Yule S. How do surgeons make
intraoperative decisions? Qual Saf Health Care. 2007;
16(3):235-239.
24. Harvey N, Fischer I. Development of experience-based
judgment and decision making: the role of outcome
feedback. In: Betsch T, Haberstroh S, editors. The
Routines of Decision Making. Hoboken, New Jersey,
USA: Taylor and Francis, 2005. p. 119-137.
25. Cristancho SM, Vanstone M, Lingard L, LeBel M-E,
Ott M. When surgeons face intraoperative challenges:
a naturalistic model of surgical decision making. Am J
Surg. 2013;205(2):156-162.
26. Vidulich MA, Wickens CD, Tsang P, Flach JM.
Information processing in aviation.Human Factors in
Aviation. 2nd Ed San Diego, CA: Academic Press;
2010. 175-215.
27. Grimbergen C, van Veelen M, Jaspers J. Ergonomic
limitations of laparoscopic instruments: mechanical
and robotic solutions.Primer of Robotic and Tele-
robotic Surgery. PA, USA: Lippincott Williams &
Wilkins Phil; 2004. 12.
28. Saad L, Benau EM, DeLoretta LC, Moelter ST.
Allocation of attention resources increases magnitude
of the attentional blink.Psychophysiology. Hoboken,
NJ, USA: Wiley-Blackwell; 2014 S44-S44.
8 Journal of Surgical Education
Volume ]/Number ]
] 2017
29. Schlachta CM, Ali S, Ahmed H, Eagleson R. A novel
method for assessing visual perception of surgical
planes. Can J Surg. 2015;58(2):87-91.
30. Westebring–Van Der Putten E, Goossens R,
Jakimowicz J, Dankelman J. Haptics in minimally
invasive surgery–a review. Minim Invasive Ther Allied
Technol. 2008;17(1):3-16.
31. Clark FJ, Horch KW. Handbook of perception and
human performance. Kinesthesia. 1986;1:218-224.
32. Vaughan N, Dubey VN, Wee MY, Isaacs R. Haptic
feedback from human tissues of various stiffness and
homogeneity. Adv Robot Res. 2015;1(3):215-237.
33. Basdogan C, De S, Kim J, Muniyandi M, Kim H,
Srinivasan M. Haptics in minimally invasive surgical
simulation and training. Comput Graph Appl IEEE.
2004;24(2):56-64.
34. Vassiliou MC, Feldman LS, Andrew CG, et al.
A global assessment tool for evaluation of intraoperative
laparoscopic skills. Am J Surg. 2005;190(1):107-113.
35. Wentink M, Stassen L, Alwayn I, Hosman R, Stassen
H. Rasmussen′s model of human behavior in laparo-
scopy training. Surg Endosc. 2003;17(8):1241-1246.
36. Logan GD. Toward an instance theory of automa-
tization. Psychol Rev. 1988;95(4):492.
37. Spruit EN, Band GP, Hamming JF, Ridderinkhof KR.
Optimal training design for procedural motor skills: a
review and application to laparoscopic surgery. Psychol
Res. 2013:1-14.
38. Beilock SL, Carr TH. On the fragility of skilled
performance: what governs choking under pressure?
J Exp Psychol Gen. 2001;130(4):701.
39. Diamond A. Executive Functions. Annu Rev Psychol.
2013;64(1):135-168.
40. Brady TF, Störmer VS, Alvarez GA. Working memory
is not fixed-capacity: more active storage capacity for
real-world objects than for simple stimuli. Proc Natl
Acad Sci. 2016 201520027.
41. Gallagher AG, Ritter EM, Champion H, et al. Virtual
reality simulation for the operating room: proficiency-
based training as a paradigm shift in surgical skills
training. Ann Surg. 2005;241(2):364-372.
42. Van Gog T, Paas F. Instructional efficiency: revisiting
the original construct in educational research. Educ
Psychol. 2008;43(1):16-26.
43. Clanton J, Gardner A, Cheung M, Mellert L,
Evancho-Chapman M, George RL. The relation-
ship between confidence and competence in the
 development of surgical skills. J Surg Educ. 2014;
71(3):405-412.
44. Proteau L, Blandin Y, Alain C, Dorion A. The effects
of the amount and variability of practice on the
learning of a multi-segmented motor task. Acta Psychol.
1994;85(1):61-74.
45. Meneghetti AT, Pachev G, Zheng B, Panton ON,
Qayumi K. Objective assessment of laparoscopic skills
dual-task approach. Surg Innov. 2012;19(4):452-459.
46. Stefanidis D, Scerbo MW, Korndorffer JR, Scott DJ.
Redefining simulator proficiency using automaticity
theory. Am J Surg. 2007;193(4):502-506.
47. Smith CD, Farrell TM, McNatt SS, Metreveli RE.
Assessing laparoscopic manipulative skills. Am J Surg.
2001;181(6):547-550.
48. Torkington J, Smith S, Rees B, Darzi A. Skill transfer
from virtual reality to a real laparoscopic task. Surg
Endosc. 2001;15(10):1076-1079.
Journal of Surgical Education
Volume ]/Number ]
] 2017
View publication stats
49. Zhu FF, Poolton JM, Wilson MR, Hu Y, Maxwell JP,
Masters RS. Implicit motor learning promotes neural
efficiency during laparoscopy. Surg Endosc. 2011;25(9):
2950-2955.
50. Goff BA. Changing the paradigm in surgical educa-
tion. Obstet Gynecol. 2008;112(2, Part 1):328-332.
51. Catchpole K, Mishra A, Handa A, McCulloch P.
Teamwork and error in the operating room: analysis of
skills and roles. Ann Surg. 2008;247(4):699-706.
52. Bruppacher HR, Alam SK, LeBlanc VR, et al.
Simulation-based training improves physicians′ per-
formance in patient care in high-stakes clinical setting
of cardiac surgery. Anesthesiology. 2010;112(4):
985-992.
53. Klein KJ, Ziegert JC, Knight AP, Xiao Y. Dynamic
delegation: shared, hierarchical, and deindividualized
leadership in extreme action teams. Adm Sci Q.
2006;51(4):590-621.
9