Enhancing surgical education for resource-limited settings: open appendectomy cognitive task analysis

Abstract

Open appendectomy is one of the most common procedures performed globally, especially in low- and middle-income countries (LMICs). In many LMICs, surgical education is limited by personnel shortages. Developing effective teaching methods for resource-limited environments may enhance the availability of a trained workforce. Cognitive task analysis (CTA) is an effective method to obtain expert input to define operative steps and cognitive processes in complex procedures. The aim of this study was to perform the first CTA for open appendectomy in an effort to develop a teaching module for practitioners in LMICs. Twelve expert general surgeons completed semi-structured interviews which were recorded via Zoom. Each expert had previously performed > 100 open appendectomies. Each interviewee described the entire procedure and then answered specific questions to inform surgical decision making, anatomic landmarks, and error recognition/avoidance. The responses were collated by two independent reviewers into a CTA model which then underwent review through a multi-disciplinary surgical education team. Final steps were presented back to the experts for feedback and modifications and tested on a simulator. Completeness of each expert’s interview was determined by two metrics: time and percentage of steps on the compiled model that the expert surgeon described. The CTA identified five main steps: preoperative patient preparation, safe entry into the abdomen, identify the appendix, appendectomy, and abdominal closure. Each step had additional sub-steps for a total of 24 procedural steps. Available equipment/supplies and critical decision point descriptions provided the most variability. The median completeness score for the unstructured portion of the interview was 76% (IQR 68–80). Using CTA, we defined the essential operative steps, decision points, and areas of potential error with performing an open appendectomy. These results provide a framework that can guide intraoperative instruction and the development of a teaching module for open appendectomy that can be implemented in LMIC to enhance surgical education.