The lack of depth cues and haptic feedback makes minimally invasive surgery a cognitive challenge. It is therefore important to know which individuals are expected to perform well in minimally invasive surgery. In cognitive psychology, methods are available with which one can measure different cognitive thinking styles. It is well known that these cognitive styles correlate with many different tasks. We investigated whether this method can also predict performance on a box trainer (Lübeck Toolbox®), a device for training laparoscopic surgery. If so, the method might help to select and train those people who will most likely develop high skills in minimally invasive surgery.
Thirty medical students and thirty non-medical students performed five laparoscopic surgical tasks on a box trainer. We measured the time required and the errors participants made on each task. Their cognitive style was measured with a method from cognitive psychology that distinguishes between people who think visually, spatially, or verbally. Furthermore, all students completed a subset of a standard intelligence test (Wechsler Adult Intelligence Scale) and three subtests of the German Medical University Admission Test (TMS).
Participants with spatial thinking styles performed best on the box trainer. Visual and verbal cognitive styles impeded box trainer performance. Performance on the box trainer could also be predicted by the TMS and IQ scores.
The study shows for the first time that a standard method from cognitive psychology can be used to distinguish between different cognitive styles in surgical education and that these different cognitive styles affect performance on a box trainer. Since the correlation between box trainer performance and surgical proficiency is well documented, the method might be an efficient way to reduce errors and to elevate patient safety in laparoscopic surgery.
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Chau C, Tang C, Siu W, Ha J, Li M (2002) Laparoscopic cholecystectomy versus open cholecystectomy in elderly patients with acute cholecystitis: retrospective study. Hong Kong Med J 8:394–399
Ahmed I, Paraskeva P (2011) A clinical review of single-incision laparoscopic surgery. The Surgeon 9:341–351. https://doi.org/10.1016/j.surge.2011.06.003
Vogel P, Vogel DHV (2019) Cognition errors in the treatment course of patients with anastomotic failure after colorectal resection. Patient Saf Surg 13:4. https://doi.org/10.1186/s13037-019-0184-6
Seymour NE, Gallagher AG, Roman SA, O’Brien MK, Bansal VK, Andersen DK, Satava RM (2002) Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg 236:458–464. https://doi.org/10.1097/00000658-200210000-00008
Ahlberg G, Enochsson L, Gallagher AG, Hedman L, Hogman C, McClusky DA, Ramel S, Smith CD, Arvidsson D (2007) Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. Am J Surg 193:797–804. https://doi.org/10.1016/j.amjsurg.2006.06.050
Vitish-Sharma P, Knowles J, Patel B (2011) Acquisition of fundamental laparoscopic skills: is a box really as good as a virtual reality trainer? Int J Surg 9:659–661. https://doi.org/10.1016/j.ijsu.2011.08.009
Keehner M (2011) Spatial cognition through the keyhole: how studying a real-world domain can inform basic science-and vice versa. Top Cogn Sci 3:632–647. https://doi.org/10.1111/j.1756-8765.2011.01154.x
Nickel F, Kowalewski K-F, Müller-Stich BP (2015) Risikobewusstsein und training zur prävention von komplikationen in der minimal-invasiven Chirurgie. Chir 86:1121–1127. https://doi.org/10.1007/s00104-015-0097-6
Luursema J-M, Verwey WB, Burie R (2012) Visuospatial ability factors and performance variables in laparoscopic simulator training. Learn Individ Differ 22:632–638. https://doi.org/10.1016/j.lindif.2012.05.012
Keehner MM, Tendick F, Meng MV, Anwar HP, Hegarty M, Stoller ML, Duh Q-Y (2004) Spatial ability, experience, and skill in laparoscopic surgery. Am J Surg 188:71–75. https://doi.org/10.1016/j.amjsurg.2003.12.059
Hedman L, Ström P, Andersson P, Kjellin A, Wredmark T, Felländer-Tsai L (2006) High-level visual-spatial ability for novices correlates with performance in a visual-spatial complex surgical simulator task. Surg Endosc 20:1275–1280. https://doi.org/10.1007/s00464-005-0036-6
Stull AT, Gainer M, Padalkar S, Hegarty M (2016) Promoting representational competence with molecular models in organic chemistry. J Chem Educ 93:994–1001. https://doi.org/10.1021/acs.jchemed.6b00194
Hegarty M (2004) Mechanical reasoning by mental simulation. Trends Cogn Sci 8:280–285. https://doi.org/10.1016/j.tics.2004.04.001
Blazhenkova O, Kozhevnikov M (2009) The new object-spatial-verbal cognitive style model: theory and measurement. Appl Cogn Psychol 23:638–663. https://doi.org/10.1002/acp.1473
ITB Consulting GmbH (2016) Test für medizinische Studiengänge I Originalversion I des TMS, 6th edn. Hogrefe, Göttingen
Hassan I, Gerdes B, Koller M, Dick B, Hellwig D, Rothmund M, Zielke A (2007) Spatial perception predicts laparoscopic skills on virtual reality laparoscopy simulator. Childs Nerv Syst 23:685–689. https://doi.org/10.1007/s00381-007-0330-9
Lind SE, Bowler DM, Raber J (2014) Spatial navigation, episodic memory, episodic future thinking, and theory of mind in children with autism spectrum disorder: evidence for impairments in mental simulation? Front Psychol 5:1411. https://doi.org/10.3389/fpsyg.2014.01411
Knauff M (2013) Space to reason: a spatial theory of human thought. The MIT Press, Cambridge
Knauff M, Spohn W (in press) Visualiation and rationality. In: Knauff M, Spohn W (eds) The handbook of rationality. MIT Press, Cambridge
Mayer RE (2009) Multimedia learning. Cambridge University Press, Cambridge
Knauff M, Johnson-Laird PN (2002) Visual imagery can impede reasoning. Mem Cognit 30:363–371. https://doi.org/10.3758/BF03194937
Bacon AM, Handley SJ (2010) Dyslexia and reasoning: the importance of visual processes. Br J Psychol 101:433–452. https://doi.org/10.1348/000712609X467314
Knauff M, Fangmeier T, Ruff CC, Johnson-Laird PN (2003) Reasoning, models, and images: behavioral measures and cortical activity. J Cogn Neurosci 15:559–573. https://doi.org/10.1162/089892903321662949
Vajsbaher T, Schultheis H, Francis NK (2018) Spatial cognition in minimally invasive surgery: a systematic review. BMC Surg 18:94. https://doi.org/10.1186/s12893-018-0416-1
Diesen DL, Erhunmwunsee L, Bennett KM, Ben-David K, Yurcisin B, Ceppa EP, Omotosho PA, Perez A, Pryor A (2011) Effectiveness of laparoscopic computer simulator versus usage of box trainer for endoscopic surgery training of novices. J Surg Educ 68:282–289. https://doi.org/10.1016/j.jsurg.2011.02.007
Laubert T, Esnaashari H, Auerswald P, Höfer A, Thomaschewski M, Bruch H-P, Keck T, Benecke C (2017) Conception of the Lübeck Toolbox curriculum for basic minimally invasive surgery skills. Langenbecks Arch Surg. https://doi.org/10.1007/s00423-017-1642-1
Huber T, Paschold M, Hansen C, Wunderling T, Lang H, Kneist W (2017) New dimensions in surgical training: immersive virtual reality laparoscopic simulation exhilarates surgical staff. Surg Endosc 31:4472–4477. https://doi.org/10.1007/s00464-017-5500-6
Ackerman PL (1988) Determinants of individual differences during skill acquisition: cognitive abilities and information processing. J Exp Psychol Gen 117:288–318. https://doi.org/10.1037/0096-34188.8.131.528
Shiffrin RM, Schneider W (1977) Controlled and automatic human information processing: II. Perceptual learning, automatic attending and a general theory. Psychol Rev 84:127–190. https://doi.org/10.1037/0033-295X.84.2.127
Taatgen NA, Huss D, Dickison D, Anderson JR (2008) The acquisition of robust and flexible cognitive skills. J Exp Psychol Gen 137:548–565. https://doi.org/10.1037/0096-34184.108.40.2068
Brunner WC, Korndorffer JR, Sierra R, Massarweh NN, Dunne JB, Yau CL, Scott DJ (2004) Laparoscopic virtual reality training: are 30 repetitions enough? J Surg Res 122:150–156. https://doi.org/10.1016/j.jss.2004.08.006
Gallagher AG, Cowie R, Jordan-Black J-A, Satava RM, Crothers I (2003) PicSOr: an objective test of perceptual skill that predicts laparoscopic technical skill in three initial studies of laparoscopopic performance. Surg Endosc 17:1468–1471. https://doi.org/10.1007/s00464-002-8569-4
Keehner M, Lippa Y, Montello DR, Tendick F, Hegarty M (2006) Learning a spatial skill for surgery: how the contributions of abilities change with practice. Appl Cogn Psychol 20:487–503. https://doi.org/10.1002/acp.1198
Wilson JL, Whyte RI, Gangadharan SP, Kent MS (2017) Teamwork and communication skills in cardiothoracic surgery. Ann Thorac Surg 103:1049–1054. https://doi.org/10.1016/j.athoracsur.2017.01.067
Wong SY, Lee A (2006) Communication skills and doctor patient relationship. Hong Kong Med Diary 11:7–9
Terashima M, Tokunaga M, Tanizawa Y, Bando E, Kawamura T, Miki Y, Makuuchi R, Honda S, Tatsubayashi T, Takagi W, Omori H, Hirata F (2015) Robotic surgery for gastric cancer. Gastric Cancer 18:449–457. https://doi.org/10.1007/s10120-015-0501-4
Jiménez-Rodríguez RM, Rubio-Dorado-Manzanares M, Díaz-Pavón JM, Reyes-Díaz ML, Vazquez-Monchul JM, Garcia-Cabrera AM, Padillo J, De la Portilla F (2016) Learning curve in robotic rectal cancer surgery: current state of affairs. Int J Colorectal Dis 31:1807–1815. https://doi.org/10.1007/s00384-016-2660-0
Institute of Medicine (US) Committee on Quality of Health Care in America (2000) To Err is Human: Building a Safer Health System. National Academies Press, Washington, DC
This research was supported by the Deutsche Forschungsgemeinschaft [DFG Grant KN 465/6-2 to Markus Knauff]. The authors thank all participants for taking part in this study.
Armin Mathias, Peter Vogel, and Markus Knauff have no conflicts of interest or financial ties to disclose.
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Mathias, A.P., Vogel, P. & Knauff, M. Different cognitive styles can affect performance in laparoscopic surgery skill training. Surg Endosc 34, 4866–4873 (2020). https://doi.org/10.1007/s00464-019-07267-y
- Box trainer
- Spatial cognition
- Cognitive styles
- Medical assessment
- Laparoscopic surgery