The effect of an attending versus neutral observer on peg transfer and intracorporeal knot-tying laparoscopic tasks

Published:September 09, 2022DOI:



      Surgery is an outcome-based specialty where maintaining peak performance is crucial to patient care. There are a variety of identified surgeon stressors that can have an impact on performance, but one factor unique to surgical residents is the observation by an attending surgeon. This study explored how the perceived authority of the observer had an impact on the participants’ physiologic markers of stress and task completion times.


      Eighteen general surgery residents performed the Fundamentals of Laparoscopic Surgery skills intracorporeal knot-tying and peg transfer tasks in a crossover study design while under the observation of an attending and a neutral observer. Heart rate variability, mean R-R interval, the time between R spikes on an EKG, minimum heart rate, maximum heart rate, average heart rate, and time to task completion were recorded. Analyses were completed via 2 × 2 analysis of variance with repeated measures.


      When observed by an attending, participants demonstrated higher minimum, average, and maximum heart rates (P = .046, = .007, and < .001, respectively) than when observed by a neutral observer. Attending observation also significantly shortened time to task completion, relative to neutral observation (P = .022).


      Attending observation is linked to increased objective measures of stress at the time of performance with decreased task completion times. Educational efforts to optimize the response to stress during learning may lead to better outcomes.
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        • Arora S.
        • Sevdalis N.
        • Nestel D.
        • Woloshynowych M.
        • Darzi A.
        • Kneebone R.
        The impact of stress on surgical performance: a systematic review of the literature.
        Surgery. 2010; 147: 318-330
        • Arent S.M.
        • Landers D.M.
        Arousal, anxiety, and performance: a reexamination of the Inverted-U hypothesis.
        Res Q Exerc Sport. 2003; 74: 436-444
        • Maher Z.
        • Milner R.
        • Cripe J.
        • Guaghan J.
        • Fish J.
        • Goldberg A.J.
        Stress training for the surgical resident.
        Am J Surg. 2013; 205: 169-174
        • Wetzel C.M.
        • Kneebone R.L.
        • Woloshynowych M.
        • Nestel D.
        • Moorthy K.
        • Kidd J.
        • et al.
        The effects of stress on surgical performance.
        Am J Surg. 2006; 191: 5-10
        • Teigen K.H.
        Yerkes-Dodson: a law for all seasons.
        Theory Psychology. 1994; 4: 525-547
        • Hardy L.
        • Parfitt G.
        A catastrophe model of anxiety and performance.
        Br J Psychol. 1991; 82: 163-178
        • Andreatta P.B.
        • Hillard M.
        • Krain L.P.
        The impact of stress factors in simulation-based laparoscopic training.
        Surgery. 2010; 137: 631-639
        • Flinn J.T.
        • Miller A.
        • Pyatka N.
        • Brewer J.
        • Schneider T.
        • Cao C.G.L.
        The effect of stress on learning in surgical skill acquisition.
        Med Teach. 2016; 38: 897-903
        • Kim H.G.
        • Cheon E.J.
        • Bai D.S.
        • Lee Y.H.
        • Koo B.H.
        Stress and heart rate variability: a meta-analysis and review of the literature.
        Psychiatry Investig. 2018; 15: 235
        • Marteau T.M.
        • Bekker H.
        The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI).
        Br J Clinic Psychol. 1992; 31: 301-306
        • Georgiou K.
        • Larentzakis A.
        • Papavassiliou A.G.
        Surgeons’ and surgical trainees’ acute stress in real operations or simulation: a systematic review.
        Surgeon. 2017; 15: 355-365
        • Shaffer F.
        • Ginsberg J.P.
        An overview of heart rate variability metrics and norms.
        Front Public Health. 2017; 5: 258
        • Pioneer of Wearable Sports Technology
        Polar H10 heart rate sensor system.
        • EHRV
        How do you calculate the HRV score?.
        • Trudeau M.O.
        • Nasr A.
        • Carrillo B.
        • Gerstle J.T.
        • Azzie G.
        Construct validity and educational role for motion analysis in a laparoscopic trainer.
        Surg Endoscop. 2015; 29: 2491-2495
        • Nasr A.
        • Carrillo B.
        • Gerstle J.T.
        • Azzie G.
        Motion analysis in the pediatric laparoscopic surgery (PLS) simulator: validation and potential use in teaching and assessing surgical skills.
        J Pediatric Surg. 2014; 49: 791-794
        • Fundamentals of Laparoscopic Surgery
        FLS manual skills written instructions and performance guidelines.
        • Wetzel C.M.
        • Black S.A.
        • Hanna G.B.
        • Athanasiou T.
        • Kneebone R.L.
        • Nestel D.
        • et al.
        The effects of stress and coping on surgical performance during simulations.
        Ann Surg. 2010; 251: 171-176
        • Vogel S.
        • Schwabe L.
        Learning and memory under stress: implications for the classroom.
        NPJ Sci Learn. 2016; 1: 1-10
        • Anton N.E.
        • Beane J.
        • Yurco A.M.
        • Howley L.D.
        • Bean E.
        • Myers E.M.
        • et al.
        Mental skills training effectively minimizes operative performance deterioration under stressful conditions: results of a randomized controlled study.
        Am J Surg. 2018; 215: 214-221
        • Wemm S.E.
        • Wulfert E.
        Effects of acute stress on decision making.
        Appl Psychophysiol Biofeedback. 2017; 42: 1-12