Department of Surgery, Columbia University Medical Center, New York, NY.
Department of Surgery, Columbia University Medical Center, New York, NY.
Surgery. 2020 Jan;167(1):241-249. doi: 10.1016/j.surg.2019.03.035. Epub 2019 Oct 22.
Safe performance of laparoscopic transabdominal adrenalectomy requires the application of a complex body of knowledge and skills, which are difficult to define, teach, and measure. This qualitative study aims to characterize expert behaviors, decisions, and other cognitive processes required to perform laparoscopic transabdominal adrenalectomy.
Hierarchical and cognitive task analyses for right and left laparoscopic transabdominal adrenalectomy were performed using semi-structured interviews and field observations of experts. Verbal data was supplemented with published literature, coded and thematically analyzed using constructivist grounded-theory by 2 independent reviewers.
A conceptual framework was synthesized. Sixty-eight tasks, 46 cognitive behaviors, and 52 potential errors were identified and categorized into 8 procedural steps and 8 fundamental principles: anticipation, exposure, teamwork or communication, physiology, dissection techniques, oncologic margins, tactical modification, and error recovery. Experts emphasized the importance of creating a 3-dimensional mental model of the anatomy or pathology (eg, aberrant vessels, tumor location) that is consistently fine-tuned throughout the operation, with conscious awareness of danger zones (eg, medial arc). Despite variations in dissection techniques, experts highlighted 2 themes: macrodissection and microdissection, with emphasis on nonlinear motions and effective transitions between the 2 when appropriate.
This study defines behaviors and competencies that are essential to performing laparoscopic transabdominal adrenalectomy effectively and safely.
安全施行腹腔镜经腹腔肾上腺切除术需要应用复杂的知识和技能体系，这些知识和技能不仅难以定义、教授和衡量，而且具有个体差异性。本研究旨在通过定性研究来确定执行腹腔镜经腹腔肾上腺切除术所需的专家行为、决策和其他认知过程的特征。
使用半结构化访谈和现场观察对右、左腹腔镜经腹腔肾上腺切除术进行层次和认知任务分析。口头数据补充了发表的文献，由 2 位独立审查员使用建构主义扎根理论进行编码和主题分析。
综合了一个概念框架。确定并分类为 8 个程序步骤和 8 个基本原则的有 68 项任务、46 项认知行为和 52 个潜在错误：预期、暴露、团队合作或沟通、生理学、解剖技术、肿瘤学边缘、战术调整和错误恢复。专家强调了在整个手术过程中创建解剖结构或病理（例如，异常血管、肿瘤位置）的三维心理模型的重要性，并且始终对危险区域（例如，内侧弧）保持警惕。尽管解剖技术存在差异，但专家强调了 2 个主题：宏观解剖和微观解剖，重点是非线性运动以及在适当情况下两者之间的有效转换。
本研究定义了有效和安全施行腹腔镜经腹腔肾上腺切除术所必需的行为和能力。
