Postoperative video debriefing reduces technical errors
in laparoscopic surgery
Giselle G. Hamad, M.D., F.A.C.S.a,*, Matthew T. Brown, Ph.D.b,
Julio A. Clavijo-Alvarez, M.D., Ph.D.a
aDepartment of Surgery, University of Pittsburgh, 3380 Boulevard of the Allies, Suite 390, Pittsburgh, PA 15213, USA
bThe Edge School for Athletes, 700 77 Street, SW, Calgary, Alberta, Canada, T3H 5R1
Manuscript received March 28, 2006; revised manuscript October 3, 2006
Background: Because of the learning curve required to master laparoscopic procedures, there is a
growing concern that patient safety may be compromised due to technical errors by a novice surgeon. We
evaluated the effect of videotape debriefing on the performance of a complex laparoscopic procedure.
Methods: Twenty-four surgical residents performed a laparoscopic jejunojejunal anastomosis under the
supervision of a single laparoscopic surgeon. All procedures were videotaped. Half of the residents
underwent video debriefing. Videotapes were analyzed for knot-tying time, anastomotic time, and fre-
quency of minor technical errors and adverse events. The performance of the debriefed group was
compared with a non-debriefed group.
Results: Knot-tying time, minor errors, and anastomotic time were similar between the debriefed and
non-debriefed groups. However, adverse events from technical errors were more frequent in the non-
debriefed group (?2? 7.647, P ? .006).
Conclusions: Postoperative video debriefing is an effective educational tool for reducing adverse events
during a complex laparoscopic procedure. © 2007 Excerpta Medica Inc. All rights reserved.
Keywords: Adverse events; Debriefing; Laparoscopic surgery; Patient safety; Skills assessment; Surgical education
Laparoscopic surgery, particularly the laparoscopic Roux-
en-Y gastric bypass, continues to endure tremendous scru-
tiny. The epidemic of morbid obesity has created a seem-
ingly insatiable demand for laparoscopic bariatric surgery.
The number of bariatric operations increased nearly 5-fold
between 1998 and 2002, with a 44-fold increase in laparo-
scopic bariatric surgery, compared to a 3-fold increase for
open bariatric surgery . Unfortunately, mortalities and
morbidities resulting from technical complications have
gained public attention . Consequently, the American
Society of Bariatric Surgery and the Society of American
Gastrointestinal Endoscopic Surgeons responded by creat-
ing guidelines for granting privileges in laparoscopic bari-
atric surgery in 2003 [3,4]. Founded in 2004, the Surgical
Review Corporation has established rigorous standards for
designating a bariatric surgical practice as an American
Society of Bariatric Surgery Center of Excellence. The
American College of Surgeons has developed a Bariatric
Surgery Center Network Accreditation Program, which uses
a national database to determine risk-adjusted surgical out-
comes in an effort to optimize quality of care.
However, despite these recommendations, the optimal
method for promoting mastery in minimally invasive sur-
gery remains elusive. There is clearly a need for a tool for
assessing performance of complex laparoscopic procedures
with the objectives of minimizing technical errors and im-
proving patient safety. This study evaluated an educational
intervention designed for this purpose.
Debriefing has been demonstrated to optimize learning and
outcomes in a variety of performance environments [5–11]. In
this study, debriefing was employed as an educational tool for
surgical residents learning a complex laparoscopic procedure.
performance of a laparoscopic jejunojejunostomy.
Twelve third-year general surgical residents with no pre-
vious exposure to laparoscopic bariatric surgery performed
a laparoscopic jejunojejunostomy during part of a laparo-
* Corresponding author. 300 Halket St. #5518, Pittsburgh, PA 15213.
Tel.: ?1-412-641-2080; fax: ?1-412-641-7878.
E-mail address: firstname.lastname@example.org
The American Journal of Surgery 194 (2007) 110–114
0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved.
scopic Roux-en-Y gastric bypass  under the direct su-
pervision of a single experienced laparoscopic surgeon. The
residents were observed during their minimally invasive
surgery rotation in which they undergo one-on-one training
with a single attending surgeon, similar to an apprentice-
ship. During their rotation, all residents performed basic
laparoscopic procedures, which did not involve laparo-
scopic intracorporeal suturing (laparoscopic cholecystec-
tomy, diagnostic laparoscopy, laparoscopic ventral hernior-
constituted less than 10% of their cases on the rotation. The
residents did not receive any formal demonstration preop-
eratively or standardized preoperative instruction but were
encouraged to read about the procedure in preparation for
After pneumoperitoneum was established, 5 or 6 access
ports were inserted (Versaport; Autosuture, Norwalk, CT).
With the patient in the supine position, the jejunum and
small bowel mesentery were divided 40 cm distal to the
ligament of Treitz with an endoscopic linear stapler (Endo
GIA plus, Autosuture). A Penrose drain was sutured to the
end of the jejunum distal to the small bowel division using
a laparoscopic suturing device (Endostitch, Autosuture). A
75-cm Roux limb was measured for a body mass index less
than 50 kg/m2or a 99-cm limb for a body mass index ?50
kg/m2. A 2-0 polyester stay suture was placed to approxi-
mate the 2 limbs of intestine, and a side-to-side jejunojeju-
nostomy was created with a linear stapler. The enterotomy
for the stapler was closed transversely with a linear stapler.
Antiobstruction sutures of 2-0 polyester were placed prox-
imally and distally. The mesenteric defect was closed with
continuous 2-0 silk suture. All procedures were directly
recorded onto a videocassette from the laparoscopic camera
(Stryker, San Jose, CA).
Six consecutive residents, constituting the first-half of
the the Minimally Invasive Surgical residents studied, did
not undergo debriefing, which was introduced as a teaching
tool after those 6 residents had completed their minimally
invasive surgical rotation. The subsequent 6 consecutive
residents underwent video debriefing. They reviewed the
videotaped procedure with the attending surgeon on the
same day in a single debriefing session per case. The at-
tending surgeon and resident appraised the performance
aloud, discussing both the successes and errors of the pro-
cedure. During the video assessment, the resident was en-
couraged to ask questions and to identify skills or strategies
that could have been improved. A collaborative summary
statement by both the attending and resident recapitulated
the lessons learned from the observed procedure, and de-
fined goals and interventions to improve the performance of
subsequent cases. Video debriefing was performed only
after laparoscopic jejunojejunostomy and not for other lapa-
roscopic procedures (eg, cholecystectomy, herniorrhaphy).
All videos were analyzed for frequency of minor tech-
nical errors and adverse events. Minor errors included drop-
ping tissue or suture, inadvertently catching the needle on a
loop of suture, twisting the suture without completing a
knot, and passing the needle inadvertently through adjacent
tissue while tying. Examples of adverse events included
breaking a suture, creation of an ischemic end of the divided
jejunum requiring resection, and tears of intestinal serosa or
mesentery requiring repair.
The time required to tie 5 intracorporeal knots with a
laparoscopic suturing device was measured for every suture.
The time required to perform the jejunojejunal anastomosis,
excluding the time for the Roux limb measurement, was
measured for each case. The mean knot-tying time, mean
anastomotic time, and rates of minor errors and adverse
events in the debriefed group were compared with those of
the non-debriefed group.
This study was approved by the Total Quality Council of
the University of Pittsburgh Medical Center.
Results are expressed as mean values ? SD. The groups
were compared using repeated measures of analysis of vari-
ance for the continuous variables. The Tukey-Kramer test
for multiple comparisons was used for post hoc compari-
sons and chi-square analysis was used for the nomimal data.
P ? .05 was considered statistically significant.
There were no conversions to open gastric bypass. The
mean number of laparoscopic jejunojejunostomies was
12.7 ? 1.2 in the non-debriefed group and 13.8 ? 1.3 in
the debriefed group (P ? .14). The mean knot-tying time
decreased by 44% for the non-debriefed group and by
49% for the debriefed group from week 1 to week 4 (Fig.
1). The standard deviation for knot-tying time decreased
progressively for both groups, reflecting an improvement
in consistency of knot tying. There was a significant
difference between weeks 1 and 3 (P ? .05), with a
plateau after week 3. However, repeated measures anal-
ysis of variance (ANOVA) showed no difference be-
tween groups throughout the 4 weeks of evaluation for
mean knot-tying time.
The rate of minor errors decreased by 59% for the non-
debriefed group and by 29% for the debriefed group from
week 1 to week 4 (Fig. 2). The standard deviation for minor
Fig. 1. Mean time to tie 5 laparoscopic intracorporeal knots versus number
of weeks of the rotation. Non-debriefed versus debriefed, P ? .33. *P ?
.05 compared to wk 1.
G.G. Hamad et al. / The American Journal of Surgery 194 (2007) 110–114
errors decreased from week 1 to week 4. There was a
significant difference between weeks 1 and 2 in both groups
(P ? .05), with a plateau after week 2. There was no
difference between groups throughout the 4 weeks of eval-
uation for the rate of minor errors per case by repeated
measures of ANOVA.
The mean time for performance of the jejunojejunostomy
decreased by 29% for the non-debriefed group and by 36%
for the debriefed group from week 1 to week 4 (Fig. 3). The
standard deviation for anastomotic time decreased from
week 1 to week 4. There was a significant difference in
anastomotic time between weeks 1 and 3 (P ? .05), with a
plateau after week 3. Repeated measures ANOVA showed
no difference between groups throughout the 4 weeks of
evaluation for mean anastomotic time.
There was a significantly higher rate of adverse events in
the non-debriefed group compared to the debriefed group
(26.5% vs 7.3% for debriefed, ?2? 7.647, P ? .006).
Minimally invasive surgical educational methods con-
tinue to evolve. Recently, there has been a growing interest
in the objective assessment of surgical competency; the
Society of American Gastrointestinal and Endoscopic Sur-
geons developed the Fundamentals of Laparoscopic Surgery
program in response to this need . Traditional surgical
outcome parameters include morbidity, mortality, duration
of hospital stay, estimated blood loss, and operative time.
However, for optimal assessment of progress in technical
proficiency, metrics must be applied to standardized surgi-
cal tasks so that quantitative values can be evaluated .
These methods have major implications for credentialing
and accreditation for complex laparoscopic procedures.
Because of the tremendous patient demand for minimally
invasive surgery, particularly laparoscopic bariatric surgery,
many surgeons have rapidly embraced this technique, in-
cluding those with limited formal training in advanced lapa-
roscopy. Unfortunately, significant complication rates have
been reported from surgeons early in their learning curve
. The learning curve for full competence in this proce-
dure is reported to be approximately 100 cases . Nguyen
et al demonstrated that an operative experience of greater
than 75 cases is associated with shorter operative time and
hospital stays and fewer major complications . Never-
theless, case volume alone does not corroborate compe-
tency. A method for reducing surgical errors and improving
proficiency is critically needed. The objective of this study
was to demonstrate the efficacy of a strategy to reduce the
number of cases required to ascend the lengthy learning
curve associated with a complex laparoscopic procedure.
The recognition and discussion of errors and adverse
events play a vital role in graduate medical education. The
morbidity and morbidity conference, a mainstay of surgery
residency programs, is founded on the importance of critical
feedback and learning from errors . By the same token,
using postoperative debriefing, residents would benefit from
regularly reviewing and critiquing their own surgical per-
formance, thereby improving their skills with subsequent
Debriefing has been used as a performance enhancement
tool in the fields of law enforcement , marketing ,
occupational therapy , education , psychology ,
and medicine [6,11]. The objective is to ensure that appro-
priate and complete lessons have been drawn from a per-
formance . The intervention in the current study
combined self-observation with instructor feedback, an ap-
proach supported by Paul et al , who reported that
medical students believed that self-observation made them
aware of strengths and weaknesses in their clinical skills,
and that commentary from peers and instructors further
enhanced this development. The details that an individual
recalls from an experience may be distorted and incomplete
if left to memory, thereby compromising the lessons
learned. The practice of actively reviewing a performance
with the trainee promotes the acquisition of accurate feed-
back that will guide the refinement of their skills. Further-
more, debriefing immediately following a performance fa-
cilitates learning by enabling the trainee to articulate the
teaching points which a mentor can correct and reinforce
while the experience is being assimilated , instead of
relying on an inaccurate memory of a past performance.
The role of video in the feedback process is supported by
Fireman et al , who demonstrated that self-observation
promotes the acquisition and transfer of procedural knowl-
edge necessary for problem solving. The authors deter-
mined that specific information presented during the video
Fig. 3. Mean time to perform a laparoscopic jejunojejunal anastomosis
versus number of weeks of the rotation. Non-debriefed versus debriefed,
P ? .81. *P ? .05 compared to wk 1.
Fig. 2. Mean number of minor technical errors per case versus number of
weeks of the rotation. Non-debriefed versus debriefed, P ? .11. *P ? .05
compared to wk 1.
G.G. Hamad et al. / The American Journal of Surgery 194 (2007) 110–114
presentation was less important than observing the actual
prior performance, challenging the traditional stance that an
instructor’s verbal feedback alone is adequate. Videotape
feedback, including self-observation and feedback from an
instructor, has been shown to enhance performance in the
fields of education , coaching , athletics [24,25],
and medicine .
Video-enhanced feedback has been shown to improve
performance of complex manual skills. Hodges et al 
demonstrated that performers of a bimanual coordination
pattern were better able to distinguish between correct and
incorrect movement patterns when such feedback was pro-
vided. That is, video feedback enhances the discrimination
process, the same process that is critical to the refinement of
operative skills. Individuals receiving video feedback
showed better performance in acquisition and retention than
the non-feedback group. Nakada et al found that videotape
analysis improved laparoscopic suturing by urologists .
High-resolution laparoscopic video imagery provides an
accurate illustration of the surgical performance . Dur-
ing debriefing, the attending surgeon can use the video
images to support their critique. Furthermore, the trainees
are less apt to distort their recollection of their performance;
unlike memory, the videotaped events are irrefutable. The
standardization of the jejunojejunostomy further promotes
the residents’ education; the resident follows discrete, re-
producible steps .
We did not expect the trends in knot-tying time, time
for completing the anastomosis, and minor errors to be
similar in both groups. The attending’s intraoperative
corrections in the operative theatre and the residents’
independent practice sessions outside of the operating
room may explain the parallel trends in skill performance
improvement. Intraoperative feedback and independent
practice could affect the learning curve for the procedure
and could augment the residents’ knowledge of adverse
events. Nevertheless, the difference in the rate of adverse
events is a significant finding, and carries implications for
patient safety and quality improvement. It is plausible
that the debriefing discussions were more effective than
intraoperative critique in identifying critical maneuvers or
strategies that would reduce adverse events in subsequent
procedures. In the setting of a technically challenging pro-
cedure, debriefing may be a useful tool not only for rein-
forcing the concurrent intraoperative feedback but also for
expanding a resident’s repertoire beyond the straightfor-
Limitations of this study include the small number of
subjects, which is limited by the number of surgical resi-
dents in the training program and by the lack of random-
ization. A limiting factor in carrying out a randomized study
is that the residents have declined to be randomized because
they unanimously wish to undergo the debriefing sessions.
Another possible criticism of the study is that the non-
debriefed residents were trained prior to the debriefed res-
idents, and that those cases were earlier in the author’s
experience. Theoretically, one might infer that a steep learn-
ing curve could have contributed to the difference in ad-
verse events. However, when the non-debriefed residents
were trained, the attending surgeon had already ascended
the learning curve  and by that time, had performed
more than 180 laparoscopic gastric bypasses as an attend-
ing. Regardless, it is undeniable that with more cases and
more experience, a surgeon has a heightened alertness for
avoiding past complications.
Debriefing has the potential to improve the efficacy of
minimally invasive surgical education. In July 2003, the
Accreditation Council for Graduate Medical Education be-
gan enforcing a policy limiting the work week for residents
to 80 hours . A growing concern among surgeons and
surgery residents alike is whether compliance with these
policies compromises training and quality of care because
of a reduction in the number of operative cases [32,33].
Among surgical residents, the work hour restrictions are
perceived to have a negative impact on education and sur-
gical proficiency because the 80-hour restriction limits the
quantity of surgical procedures that can be performed. Grad-
uate surgical education is based on repetitive patient en-
counters, maximizing operative cases, and continuity of
care, all of which could be diminished by the duty hour
restrictions. The ramifications of the work hour restrictions
on patient safety and outcomes remain unclear.
Surgical training was originally predicated on the obser-
vation of a case in the operating room and subsequent
performance of the procedure, hence the popular adage,
“Watch one; do one; teach one.” In the era of the 80-hour
work week, preoperative preparation and education by sur-
gical residents outside of the operating room have become
even more critical for enhancing their technical skills and
improving surgical performance. Considering the stakes in-
volved when trainees operate on live patients, it is vital that
residents maximize the learning and performance refine-
ment gained from each operation. Given the recent public
attention on patient safety and the focus on quality improve-
ment in surgery, there is a critical need for innovative
educational methods so that the time spent in the operating
room is used optimally and so that quality of care is pre-
The current study validates the use of video debriefing as
an effective educational tool for reducing adverse events by
surgeons learning a complex laparoscopic procedure. This
educational strategy has the potential to improve the safety
of the laparoscopic gastric bypass, which has a steep learn-
ing curve [16,17]. Video debriefing holds promise for en-
hancing surgical education and improving surgical perfor-
mance and may play a role in distance surgical education
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