Measuring Intra-Operative Decision-Making During Laparoscopic Cholecystectomy: Validity Evidence for a Novel Interactive Web-Based Assessment Tool

Amin Madani, MD1, Yusuke Watanabe, MD1, Philip Pucher, MD, PhD2, Elif Bilgic, BSc1, Melina C Vassiliou1, Rajesh Aggarwal, MD, PhD1, Gerald M Fried, MD1, Liane S Feldman, MD1. 1McGill University, 2Imperial College London

INTRODUCTION: Errors in judgment during laparoscopic cholecystectomy can lead to bile duct injuries.  Despite the strong correlations between patient outcomes, expert performance and advanced cognitive skills, current methods to evaluate these complex skills remain subjective, rater- and situation-dependent, and non-systematic.  The purpose of this study was to develop objective metrics using a web-based platform, and to obtain validity evidence for their assessment of decision-making during laparoscopic cholecystectomy.

METHODS AND PROCEDURES: An immersive and interactive online learning platform was developed (  Trainees and attending surgeons from 6 institutions completed a 12-item assessment tool.  The items were developed to target critical decisions, based on comprehensive cognitive and hierarchical task analyses about achieving a Critical View of Safety. Five items required subjects to draw their answer on the surgical field and accuracy scores were calculated based on an algorithm derived from experts’ responses (Figure 1). Test-retest reliability, internal consistency, and Spearman’s correlation with self-reported experience, Global Operative Assessment of Laparoscopic Skills (GOALS) score and Objective Performance Rating Scale (OPRS) score were calculated.  Scores of novices, intermediates and experts were compared using Analysis Of Variance. Five-point Likert scale questionnaires were administered to evaluate the platform’s usability, feasibility and educational value.

RESULTS: Thirty-nine subjects (17 attending surgeons, 22 residents) completed the assessment.  There was high test-retest reliability (intraclass correlation coefficient=0.95; n=10) and internal consistency (Cronbach’s alpha=0.87).  The assessment tool demonstrated significant differences between novices, intermediates and experts in total exam score (all 12 items; p<0.01) and total accuracy score (5 drawing items; p<0.01) (Figure 2).  There was a high correlation between total case number and total score (rho=0.83).  Intra-operative assessments were available for 9 residents, with moderate to high correlation between total score and GOALS (rho=0.63), and between total score and OPRS (rho=0.87).  Most subjects either agreed or strongly agreed that the assessment tool was easy to use (n=32 (82%)), facilitates development of intra-operative decision-making (n=31 (79%)), and should be integrated into surgical training (n=31 (79%)).

CONCLUSION: This study provides validity evidence for a novel web-based interactive platform to objectively assess intra-operative decision-making during laparoscopic cholecystectomy.  Given the consequences of bile duct injuries and the importance of advanced cognitive skills, the integration of this tool into surgical training may facilitate the development of expertise and improve patient safety.

Figure 1: Screenshot of sample user response when asked to identify where they would start dissecting the hepato-cystic triangle.

Figure 2: Mean total score for each group.

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