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Evaluation of Orientation Strategies in Laparoscopic Cholecystectomy

Sodergren, Mikael H. MRCS*; Orihuela-Espina, Felipe PhD*,†; Clark, James MRCS*; Teare, Julian FRCP*; Yang, Guang-Zhong PhD; Darzi, Ara KBE*

doi: 10.1097/SLA.0b013e3181e49683
Original Articles: ORIGINAL STUDY

Objective: Using eye-tracking technology, we aim to examine if there are common patterns of visual attention strategies employed by surgeons which are associated with a greater chance of successful reorientation when disorientated during laparoscopic cholecystectomy.

Summary Background Data: Laparoscopic cholecystectomy is one of the most commonly practiced and minimally invasive procedures with a recognized morbidity relating to bile duct injuries. It has been suggested that the majority of bile duct injuries occur as a result of operator disorientation.

Methods: A total of 21 surgeons of varying experience participated in the study. Attention as represented by gaze was captured, as subjects were presented with 8 images of various stages of a laparoscopic cholecystectomy with the task of interpreting the orientation of the image. Subject fixations on relevant anatomic structures within the images were analyzed and a visual behavior profiling algorithm was applied to compare the behavior of individual surgeons.

Results: No difference in orientation performance between seniority levels or with laparoscopic experience was found. Key structures used as “anchor objects” to successfully orientate at various stages of a laparoscopic cholecystectomy were unveiled, and a representative successful visual attention behavior for each stage of the operation was described.

Conclusion: There are discernable and quantifiable visual attention strategies used by surgeons during laparoscopic cholecystectomy associated with successful orientation. By quantifying visual behavior and by inference attention processes of surgeons, this study represents an initial step in attempting to decrease the morbidity associated with disorientation. This study raises some important questions. First, can these common reorientation strategies be taught to aspiring surgeons as part of a curriculum thereby decreasing the learning curve associated with the apparent need for experience in laparoscopy? Second, can these common reorientation strategies be taught to those surgeons who consistently performed below average to increase their performance?

Disorientation is a recognized problem in laparoscopic surgery with associated patient morbidity. This study evaluates reorientation strategies of surgeons during various stages of a laparoscopic cholecystectomy. Using eye tracking technology successful strategies are characterized and described and future implications of these are discussed.

*Department of Biosurgery and Surgical Technology, Imperial College London, St. Mary's Hospital, London, United Kingdom;

Institute of Biomedical Engineering, Imperial College London, London, United Kingdom.

There were no sources of funding or grants specifically received for this research. Mikael Sodergren holds a BRC clinical fellowship grant supporting a wider research project.

Reprints: Mikael H. Sodergren, MBChB, MRCS (Eng), Department of Biosurgery and Surgical Technology, Imperial College London, Academic Surgical Unit, 10th Floor QEQM, St. Mary's Hospital, South Wharf Road, London, W2 1NY, United Kingdom. E-mail

© 2010 Lippincott Williams & Wilkins, Inc.