Discussion
mistakes
The present randomized study shows that SA training as part of a multimodal training concept can lead to a significant improvement in laparoscopic performance during the early learning curve. The results were consistent in exploratory analyses for additional performance metrics and error rates. Significant group differences appear in favor of the SA-group for the OSATS score, the GOALS score, as well as the error score. These results imply that SA training helps to improve performance. Thus, the primary endpoint of this study was met. Due to the prospective randomized design and rigorous implementation, it can be assumed that the SA training is causal for the difference.The finding that SA training as part of non-technical skills (NTS) training has a positive impact not only on cognitive but also on psychomotor skills is consistent with previous research [The intervention in the present study trained SA and thus an important cognitive function. It led to a reduction in errors in laparoscopic novices. The relationship between lack of SA and the occurrence of errors has been reported in the literature previously [However, despite displaying a superior performance, the SA-group took the same time as the control group to complete the LC. Graafland et al. showed a better response to equipment failure in the SA-trained group, but also found no difference in time required. McCulloch et al. observed an increase in NTS and attitude toward safety during LC, but no change in operating time after the surgeons participated for several months in aviation-style resource management training [The evaluation questionnaire demonstrated that the video clips with SA training were rated more useful and led to higher concentration and learning effects than video clips without SA training. The correlations between the perceived subjective learning effect, level of concentration during training, and the expedience of cognitive training offer the conclusion that only those, who were able to concentrate on the video clips, stated a learning effect. These findings are in line with previous research stating that concentration and attention are crucial to learning effects [The results of the subgroup analysis should be investigated in further studies as they only have explorative character. Various factors and traits influence the acquisition of laparoscopic skills, and this study indicates not all groups benefitted equally from SA training. Male and right-handed participants seem to have benefited from the SA training, but female and left-handed trainees did not benefit equally. Since the participants did not receive any instructions and female participants might perform worse than their male colleagues without instructions [In summary, SA training appears to be a useful complimentary tool to hands-on training in the multimodal training curriculum for novice laparoscopists. At this point, it has yet to be investigated whether SA training for LC can be applied to other, more difficult operations, and to what extent more difficult SA training sessions can provide more experienced surgeons with useful training. It is reasonable to assume that multimedia-based vicarious learning will be adopted by surgeons. A study shows the growing importance of collegial exchange via multimedia posts on social platforms, with a focus on learning through the mistakes and experiences of others [Implementation of SA in the OR might be achieved through interceptive auto-suggestive questions the resident asks herself/himself while assisting and watching. Questions like “What’s going on at the moment?”, “What might happen next?”, and “Do I run into any risks soon?” help train SA. However, whether SA skills learned in a training center are applicable to the OR as well as the feasibility of its implementation and to what extent better SA means better outcomes in terms of mortality and morbidity for patients, needs to be verified in further studies. The feasibility of implementing this multimodal training concept can be difficult in smaller hospitals with limited resources. One way to overcome this problem is to have training centers at larger hospitals offer multimodal training for residents from smaller hospitals.The integration of this study into the elective course came with limitations. Due to administrative reasons, the elective course was supervised by a total of two tutors and three assistants. Also, the MIS training center of the Surgical University Hospital Heidelberg is accessible and in use for various learning and exercise groups and it could not be guaranteed that only a single tutoring session took place at a given time. Despite previous arrangements, inter-rater validity and a generally valid schedule, individual differences in tutoring and distraction cannot be ruled out entirely. Another limitation of this study was that the participants were students. Medical students do not decidedly represent novice surgeons. However, all participants were novices and therefore comparable with each other. Equally limiting was the porcine cadaver liver model, from which no conclusions can be drawn as to whether the recorded increase in surgical performance is also associated with a benefit for alive human patients. On the other hand, the pig cadaver model is a well-established model for LC because of the similar anatomy, and it has already been shown that the technical skills learned can be transferred to humans in the operating room [In conclusion, video-based SA training with a focus on potential errors during the critical steps of LC is beneficial in the early phase of laparoscopy training. Efficient training of novice laparoscopic surgeons is becoming increasingly important and SA training offers a valuable opportunity to add to multimodal training curricula. Video-based SA training could also be integrated into the concept of vicarious learning via social platforms and would thus be easily accessible. Further studies should focus on transferability to the OR and improved patient safety. Additionally, this is one aspect of a comprehensive training curriculum in addition to simulation and guided real cases.