The Effect of Preoperative Simulation on Surgical Performance

Despite significant advances in both understanding and technology, complications of surgical care have become a major cause of death and disability worldwide. A substan- tial proportion of these complications are deemed preventable. It has been hypothesised that preparing surgeons to operate may improve performance and, by extension, pa- tient outcomes. This thesis is concerned with three fundamental investigations into the effect of preparation (described as preoperative simulation) on surgical performance. First is an investigation into the current understanding of preoperative simulation, which involves a systematic review of the literature. Broad support for preoperative simulation is demonstrated, however, the studies suffer from methodological shortcom- ings and lack theoretical grounding. Building on this, a laparoscopic sequence learning task was developed to allow the investigation of preoperative simulation under controlled conditions. This was used in three controlled, randomised crossover trials. These experimental trials demonstrated that a simplified, relevant preoperative simulation can improve simulated laparoscopic performance. Exactly what form the preoperative simulation should take is deter- mined by the nature of the task/operation being performed and is likely to reflect how that procedure was learnt. Additionally, preoperative simulation can alter an opera- tors approach to completing a task, overriding a suboptimal but preferred method, to condition them to use a better method of completing the procedure. Finally, the natural experiment of repeating a procedure during an operative list was used to explore the effect of preoperative simulation in clinical practice. An inves- tigation of approximately a half million operations was conducted, which demonstrated that the order in which procedures are performed has a predictive relationship with operative duration (a surrogate for operative quality). This finding was relatively con- sistent across the thirty-five most common operations, and reinforced by the finding that switching procedures leads to significantly increased operative times. These investigations support the view that preoperative simulation improves surgi- cal performance.