Preoperative warm-up the key to improved resident technique

Erin Moran-Atkin, MD, Ransom Wyse, MPH, CPH, Grace Chen, MD, Bethany Sacks, MD, Hien Nguyen, MD, Anne Lidor, MD, Thomas Magnuson, MD, Michael Schweitzer, MD, Kimberley Steele, MD. Johns Hopkins University School of Medicine.

The ACGME has required that a simulation and skills lab be incorporated into surgical residency training curricula. The benefit of practicing in the lab has been studied in recent years and is well accepted. While the value of warm-up is generally accepted in other areas requiring complex motor skills, e.g. athletics and musical performance, there is little evidence to support the benefits of warm-up prior to performing surgery. We are conducting this study in an attempt to identify whether a warm-up period, just prior to operating, results in better operative technique.

Methods
All general surgery residents from PGY1 to PGY5, as well as the MIS fellow, were asked if they wished to participate in this IRB approved study. The procedures eligible for the study were laparoscopic appendectomy or cholecystectomy for junior level residents (PGY1 and 2), and laparoscopic ventral or inguinal hernia repair, colon resection, vertical sleeve gastrectomy, or Roux-en-Y gastric bypass for senior levels (PGY 3, 4, 5 and fellow). Participants were randomized to warm-up or no warm-up groups. Participants randomized to the warm-up group completed a 10 minute practice session in the simulation lab within 1 hour of starting the case, using an FLS training box. PGY1 and PGY2 training skills performed were pegboard transfer, pattern cutting, and endoloop; PGY3 to PGY5 and fellow skills were pegboard transfer, pattern cutting, intracorporeal suturing and endostitch. At the conclusion of the operation, the participant was evaluated by the attending surgeon using the validated global rating scales of Reznick and Vassiliou. The attending surgeons were blinded to the use or not of pre-procedure warm-up. The results of the questionnaire were analyzed using student T-Test with p<0.05 for significance.

Results
Pilot data was obtained enrolling 15 residents randomized to warm up (10) or no warm-up (12) for 22 laparoscopic procedures. Attending surgeon evaluations on resident performance showed a statistical significance in instrument handling (0.03) and bimanual dexterity (0.01) (Table 1). Although the rest of the grading points did not show statistical significance there was a notable improvement in overall scores. Participants’ perception of their performance during the procedure using warm-up was not significantly altered (Table 2).

Conclusion
Preoperative warm-up significantly improves bimanual dexterity and instrument handling. There did appear to be improvement in operative technique among subjects using warm-up as judged by the attending surgeon, though this effect did not reach statistical significance. The lack of self-perceived improvement by the residents may be a reflection of the high standards and intense self-critique that is common among surgical trainees. We believe that our findings, while preliminary, reflect an important finding; namely, that surgical performance, as with other areas of human performance, can be enhanced through structured warm-up activities. The potential importance of this finding justifies further data collection and replication of our findings at other institutions.