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AIMS: Correct decision making is pivotal and an integral part of surgical competency. To date there has not been an attempt to assess surgeons making decisions whilst operating. In our present study we aim to assess operative decision making by trainee and expert surgeons by using hierarchical task analysis (HTA) as a method to map out decision making in surgery. METHODS: One hundred and forty live laparoscopic operations were prospectively analyzed, independently and blindly. The operations were compared to an operative HTA, and individual case reasons for deviations noted. Factors in the operating theatre which may influence the surgeons' decisions whilst operating were assessed using a checklist. RESULTS: One hundred and nineteen elective and 21 emergency laparoscopic operations performed by 12 consultants and 14 registrars were analysed. Factors from the HTA and theatre environment checklists were categorised. Inter-rater reliability was k=0.95, k=1.00 for sub-tasks and tasks, respectively, and 0.98 between the surgeon and independent observer for the operating theatre checklist. From these data sets a psychomotor surgical decision making model was constructed. Face and content validities of the model were verified by experts in surgery and decision making. CONCLUSIONS: Dynamic surgical decision making is a multi-faceted and intricate process. We have used HTA to map this process and we present a model in surgical decision making. By understanding the mechanisms and factors which influence this process we may use it for effective, focused surgical training. We aim to use and test our model also on open major complex surgery.

Original publication




Journal article


Int J Surg

Publication Date





98 - 105


Adaptation, Physiological, Cerebral Cortex, Clinical Competence, Communication, Decision Making, Decision Support Techniques, Emotions, Ergonomics, Health Facility Environment, Humans, Laparoscopy, Memory, Motivation, Motor Skills, Operating Rooms, Prospective Studies, Reproducibility of Results, Risk-Taking, Sleep, Space Perception, Stress, Psychological, Surgical Equipment, Surgical Instruments, Task Performance and Analysis, Visual Perception