After finishing section one, candidates progressed to Section Two which was titled Artery. This section had six parts: five mandatory and one optional (as before the section optional section contained material that could only be accessed by streaming it). Each part contained one or more questions presented on one screen. Candidates had to progress in a linear way through this module from one section to the next and from one part within the section to the next. They were not allowed to skip sections or parts of a section. This was deliberately set to reduce mental tiredness by
preventing brain shifting back and forth between topics. It was also set to allow the creation of a comprehensive systematic design from start to finish. Module elements progressed from simple to more complex scenarios and the design built up
knowledge in a progressive manner. This will become clearer later in this online Cognitive Hazard Training description.
Candidates could stop the module at any point and their progress would be recorded and saved by the system. They could return to the module later and their progress would be shown on the introductory page (Appendix 11). They would see a green tick next to the parts and sections completed. Those parts could be re-entered to refresh the memory by checking previous answers and feedback. Candidates
however, could not retake the test and their previous answers could not be modified. The next section to be completed was shown in a green colour without a green tick next to it and the remaining parts and sections would be faint as they were not yet available (Appendix 11). Candidates would simply continue their progress by picking up from the last point they had reached.
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The first part in the Artery Section has two questions (Appendix 12). The first question was a multiple choice question (MCQ) with a single correct answer. It asked about the most common cystic artery anatomical variation and the answer was cystic artery doubling. The second question in this part was an extended matching item (EMI) with four laparoscopic view images. Each image had four anatomical sketches to choose from. Those images were the result of editing the coupled laparoscopic views/anatomical sketches described in the image processing section above. They had been split into their components with the marks and arrows removed. Laparoscopic views were selected as the base image and the anatomical sketches were chosen as the options in this EMI question. This arrangement replicated a real life scenario. Surgeons operate using the laparoscopic view presented on the laparoscopic machine’s screen as discussed before. They have to interpret possible anatomical variation corresponding to the laparoscopic views displayed on screen and take steps to deal with the anatomical elements safely. The same logic was used in this EMI question. Candidates had to match the laparoscopic view with the corresponding anatomical variation sketches. Those sketches were presented next to the laparoscopic view and candidates made their choice from a drop down window. Once a choice was made the rest of the anatomical sketches disappeared, leaving the selected sketch only next to the laparoscopic view (Appendix 13). This was done to reduce mental overload by removing any
distraction by the other sketches and enabling trainees to double check their answer. After matching all the images in this question, candidates hit the Next button to submit their answers. The correct answers were marked with a blue tick () and the wrong answers marked with a red cross (). Candidates were allowed another attempt to correct their mistakes as discussed before. Feedback was provided with
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the original coupled images (Appendix 14) displayed below the marked questions after the second attempt or after the first attempt if all answers were correct.
To summarise this part, trainees were asked about the most common cystic artery anatomical variation in question one. They were then questioned about matching the laparoscopic views with the corresponding cystic artery anatomical variations. This information was emphasised further by providing the coupled images as feedback.
Part Two of the Artery section put those learned laparoscopic/anatomical variation clues into practice by showing two short videos and asking about possible cystic artery anatomical variation (Appendix 15). This was followed by marking the answers and providing four extra feedback videos (Appendix 16). As described in the video editing section of this chapter, YouTube videos were downloaded, and shortened by selecting the important parts and using those parts in questions or feedback as needed. The first and second feedback videos represent an advanced stage of dissection from the previously presented two operation videos in this question. Each video showed the anatomy safely dissected in the corresponding operation and the duplicated artery clearly viewed before being clipped. A message was provided before each of those two feedback videos, to stress the different internal fat distribution affecting the level of difficulty in identifying anatomical structures in the two operations. Those two messages (Artery identification might be
easy in a thin gallbladder) and (but would require further dissection in a fatty gallbladder) are displayed before the first and second feedback videos respectively
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The third and fourth feedback videos developed the problem further. They were preceded by the following hazard warning message (Identifying anatomical clues
help predicting and planning to manage possible risks. Those risks might be simple bleeding in this case). Then the third and fourth videos showed bleeding as a result
of missing the anatomy variation clues. The third video represented simple bleeding from one of the operations presented earlier within this question. The fourth video displayed bleeding that was more difficult to control (from another operation from YouTube not presented before in this question).
The feedback page ended with the following message (Note: Artery cauterization is
the preferred method for this expert surgeon. Many surgeons might use clips. We are not recommending any particular method in this assessment. Our focus is on identifying risk clues and planning to mitigate any predicted problem using the surgeon’s experience and preferred techniques.). This message was added to stress
the module position about the bleeding control methodology used in the fourth feedback clip. The surgeon in this clip used a fair amount of cauterization which is a method used to control bleeding by burning tissues using heat generated by a special medical device. Although this is a known method and can be used safely in expert hands it can still evoke discomfort and hazard worries among some surgeons. I felt the need to make clear the module material’s neutral position about this bleeding control method to eliminate misinterpretation of the message intended. The fourth feedback video represented difficult to control bleeding, resulting from missing anatomical clues. This scenario was a possible event encountered in operations and it was not a criticism of the operating surgeon’s skills. This clip served the module aim to stress the importance of picking up clues to avoid such bleeding. Dealing with
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bleeding after it occurs is left to surgeons’ skills and the approach they would feel safe to use. Recommending one method over others was not part of this module’s aims.
Part Three of the Artery Section had a multiple choice question with a video showing the cystic artery originating from the right hepatic artery (Appendix 17). The
feedback screen had a video from the same operation just before clipping (Appendix 18). As discussed earlier, in the video processing section of this chapter, I removed voice comment, music, illustrations and any additions inserted in the selected videos. This was done to reduce distractions and prevent revealing the answer before
candidates had attempted to answer the question. I opted however to leave the surgeon’s verbal comments in this feedback video clip as it delivered a very
important safety message. The verbal comments in this clip was: (note that both the
cystic artery and the cystic duct were clipped at the same time not at different times during the surgery. Critical views were obtained by both the primary surgeon and the assisting surgeon before any clips were placed). This was very important to
further stress those safety clues and serves the module aim without distracting from the hazard shown in this clip.
Part Four asked two questions about the consequences of missing the anatomical hazard presented in Part Three, and the way to recover from this mistake if it happened (Appendix 19). I chose the single-line free text question format as it was more challenging than MCQ. This escalating question level format followed the error recovery theory for mental training logic (mentioned previously in Chapter
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Two). Dror suggested an intermediate phase of error recognition in others using interactive video clips. Clips, in Dror’s theory, progress from simple exaggerated mistakes to more hidden errors. Trainees are asked to generate possible recovery plans at the end of the process after being offered such plans earlier in training (58).
Part Four built on the information already learnt. Questions in this section progressed from asking about the most common anatomical cystic artery variation to providing laparoscopic clues about possible encountered anatomical variation. This was followed by multiple practice opportunities with escalated difficulty and
complication seriousness. Candidates were asked to generate a recovery plan in the fourth part after being shown bleeding controlled scenarios earlier.
As mentioned earlier, candidates had one attempt to answer the single-line free text questions. The system marked the answers by green tick or red cross marks and showed the model answer with a feedback video (Appendix 20). The feedback video in this part was different from all the other videos in this module so far. It was not a processed uploaded video like the others. It was streamed directly from YouTube. This video shows the effect of clipping the right hepatic artery in the form of liver ischemic colour changes. It also illustrates the surgeon’s hazard recognition and recovery from this mistake before cutting the clipped artery. The surgeon reacted to the detected mistake by removing the clips and checking liver recovery signs. All in all, the surgeon in this clip managed to recognise the hazard clues and mitigate the mistake well, avoiding permanent damage.
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Unfortunately, the owner of this video could not be contacted despite best effort. However, this video was really important to complete the aim of the module’s hazard-training. The only feasible option was to stream the video directly from YouTube as I could not download and edit it without the owner’s permission. By taking this decision I accepted the video length and the added music. I added a message above the clip, in the feedback page, to warn about the clip length and to highlight the key moments in the video. The message also included a line to further highlight the risk of missing the ischemic clues and cutting the clipped artery (Missing the hazard and failing to recover after applying the clips would have
resulted in right hepatic abscess and the need for a lobectomy.).
If I had managed to gain the video clip owner’s permission I would have removed the music and reduced the video into three short video slices. I would have taken one slice to show artery clipping and asked about the possible laparoscopic clues
resulting from making such a mistake. This would have been followed by another slice showing the liver ischemic colour change and requested candidates to generate a recovery plan. Finally, I would have shown a slice of removing the clips and the liver colour recovery along with the warning message about the consequences of missing the mistake and cutting the artery. This would have been the ideal situation but failing to gain permission forced me to use the current described format.
Part five presented yet another laparoscopic view video and asked about the corresponding cystic artery anatomical variation which was the cystic artery originating from the gastroduodenal artery in this question (Appendix 21). In the
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feedback and marking page candidates were shown two extra videos with further intra-operation artery variation (Appendix 22). These were edited videos with further rare examples of cystic artery anatomical variations encountered and dealt with safely by different surgeons. I left the on-screen labels and arrows, naming the viewed anatomical structures, in those videos to prevent confusion and reduce mental overload. Those videos show extreme and very rare anatomical variation examples so it would be fair to say many will find the presented anatomy
challenging. However, the message from this chapter was to pick up any clues that the anatomy faced might not be a standard anatomical distribution and to be cautious: Involve System Two, (as described in the cognitive theory section in Chapter Two of this thesis) to safely dissect the anatomical structures and establish a critical view before any clipping. A critical view should be established by more than one surgeon if possible, as stressed by the voice comments in the feedback clip in Part Three. Even after clipping, the surgeon should check visual clues before cutting as this might prevent damage as was the case in the feedback clip in Part Four. This message was further stressed by the written on-screen comments in the first feedback clip in this part.
Part Six was the final part of the Artery section and it included optional streaming videos which could be skipped by the candidates (Appendix 23). Candidates
however had the option to email those YouTube videos’ links to their email address for a later review. This could be done by pressing the Email Links button at the top right hand side of the screen. Each of the three optional videos was preceded by a message to highlight the hazard/anatomical variation and the key points in the video (they were chosen from the pool of videos I was unable to gain permission to
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download) to further stress the message in this section and provide extra training opportunities if trainees wished to watch them. They were not however included as part of the module to keep the message focused and keep the module within a reasonable time length.