Laparoscopic Nissen Fundoplication Assessment: Task Analysis as Model for the Development of a Procedural Checklist

Objective: Learning an advanced laparoscopic procedure is a complex process that requires clinical exposure, direct teaching, and deliberate practice. However, expert laparoscopic surgeons automate their knowledge making it difficult to teach all of the incremental steps. The aim of this study was to deconstruct the operative steps of a laparoscopic Nissen fundoplication (LNF) and develop a procedural checklist to be used for resident assessment.

Methods: A behavioral task analysis was conducted with five experts using the Delphi technique to identify all steps of a LNF. The Delphi survey included a video analysis of expert performance, two electronic iterative rounds and a final group interview to reach consensus. The created checklist was then used to assess the performance of 14 general surgery residents (3 R2’s, 6 R3’s, 4 R4’s, 1 R5), all with previous clinical experience on the Foregut Surgery Service. Participants were asked to view an instructional video created prior to the development of the checklist, and complete the procedure on a porcine model. Laparoscope video recordings of resident performance were analyzed using the created procedural checklist by a blinded observer.

Results: Results of the Delphi survey produced a 65 step procedural checklist with four major components (crural dissection, crural closure, fundic mobilization and creation of fundoplication). Thirteen of fourteen participants completed the procedure; 1 pig died during the operation. The median score for all residents who completed the procedure was 31 (range 13-38). The checklist median total score for senior residents (35.5, 34-38) was significantly higher than junior residents (29.5, 13-36)(p=0.0162). All residents were able to demonstrate knowledge of most of the major elements of the procedure as 13 dissected the crura and created the fundoplication, 12 closed the crura and 11 mobilized the fundus. Residents frequently failed to complete (>25%) several essential steps including identification and protection of the anterior vagal nerve, complete dissection of the crura to the decussation and mobilization of the esophagus into the mediastinum.

Conclusions: The Delphi technique was successful in reaching expert consensus on the procedural tasks of a LNF and in creating a valid checklist. Application of this instrument demonstrated resident knowledge of major procedural steps as well as gaps about important details of the operation. By capturing automated knowledge in a checklist form, we can scaffold resident learning and close this gap. Additional psychometric testing is needed for implementation as a high stakes assessment of surgical performance.

Session: Podium Presentation

Program Number: S027