Background

• As with all microsurgical procedures, DIEP (deep inferior epigastric artery

perforator) flaps have steep learning curves.

• As novice surgeons à experts, re-exploration rates and OR times ↓

• What cognitive + technical processes differ between novice and expert?

• Cognitive Task Analysis (CTA) deconstructs procedures à discrete tasks

and makes explicit the implicit behaviors + cognitive processes of experts.

 

Aims

To combat the learning curve for DIEP flaps through CTA by:

1. Defining the tasks, decisions, and potential errors in a DIEP flap.

2. Unveiling the expert cognitive behaviors required for success

 

Methods

• Cognitive Task Analysis

Preliminary coding + analysis based on cognitive behavior framework by

Grover for Roux-en-Y gastric bypass (Grover et. al., Surg Endoscopy, 2023)

Results

Expert Characteristics

• Microsurgery fellowship-trained

• Works in high volume breast cancer center

• Performed > 400 DIEP flaps

Results – Major Tasks and Subtasks

• 7 major tasks identified for a DIEP flap à subtasks, potential errors, technical tips and decisions (Figure 1) à master protocol

 

Potential Errors - example

“[In] some women you'll find that their [vessels] are very sensitive,

meaning that they are fragile, like if you lift up… suddenly, I just caused

this little bleed from my retraction…so then you know that you can no

longer pull as much. You have to be able to check that before you're

getting to your [main] perforators. How fragile their vessels seem.”

 

Technical Tips- example

“And with the artery you can only grab the adventitia, while you

grab all the way across [the vein]. So the way that you handle the

vessels is very different . And you actually don’t ever want to pinch a

little bit of the vein. You can cause a rip in it . And you don't want to

grab all the way across the artery because you can crush it.”

Results – Cognitive Behaviors

• Master protocol coded à modified framework

of 10 behaviors (Fig 2, right)

Operative Efficiency - example

“They just had way too much equipment…so we

paired down the sets to [only] have the instruments

that we use…trying to pay attention to what [the

scrub technician] puts on the Mayo stand, because

[it] is for the [tools] that should be readily available.”

Aesthetic Considerations - example

“Lately I've been trying to go to the fourth rib [for

chest vessel dissection] because I think [it creates] a

less noticeable defect…taking out that cartilaginous

portion of the third rib can sometimes be visible later.”

Cognitive behaviors employed throughout the major tasks of a DIEP (Fig 3.)

• Chest vessel dissection has ↑cognitive load

• Atraumatic tissue handling = most prevalent cognitive behavior

Conclusions

Protocol highlights critical areas for decision-making, error avoidance &

technical tips to perform DIEPs safely, efficiently and with optimal aesthetics.

Cognitive behaviors

• Chest vessel dissection has ↑cognitive load à critical area for teaching

• Proficiency in atraumatic tissue handling before high-stakes subtasks

Future Work

• Additional expert interviews à master protocol

• Visual framework, targeted educational and assessment tools