Cognitive task analysis of the laparoscopic totally extraperitoneal (TEP) inguinal hernia repair: Efficiency, slow-down moments and teaching principles

Abstract

Introduction The TEP repair is associated with a learning curve of at least 250 repairs. Expert surgeons' decision-making becomes automated, making it difficult for them to recognize and teach their decision-making process. We sought to deconstruct the intraoperative decision-making of the TEP repair in order to discern the key cognitive and technical teaching principles. Methods Five expert TEP surgeons participated in an individual critical decision method-based cognitive task analysis interview, supervised by an educational psychologist. Experts were asked to recall and describe their last unilateral TEP repair. Recordings were transcribed, and cognitive demand tables were created outlining operative and decision making steps. Thematic analysis was then conducted to identify common operative strategies, and agreement between experts was compared. Results Analysis of transcripts revealed 26 operative and 23 decision-making steps, yielding 9 themes: efficiency, troubleshooting, slow down moment, critical step, error avoidance, cost-saving, patient-specific, surgeon-specific, and teaching principles. Each theme had areas of overlap as well as unique operative strategies (among 13 teaching principles identified, 10 were common to >1 surgeon and 3 were unique to only one surgeon). Experts were more likely to agree in operative than in decision making steps (81% vs 56%, p Conclusions Cognitive task analysis with experienced TEP hernia surgeons identified strategies to improve efficiency, discovered critical operative cues and outlined key teaching principles for the TEP repair. These results can be integrated into instructional programming and clinical training to facilitate growth and acquisition of procedural decision making of surgical trainees.