Understanding How Experts Do It

Abstract

Background: The safe and effective performance of a posterior component separation via a transversus abdominis release (TAR) requires intraoperative judgement and decision-making skills that are difficult to define, standardize, and teach. We herein present the first qualitative study which builds a framework upon which training and objective evaluation of a TAR can be based. Methods: Hierarchical and cognitive task analyses for a TAR procedure were performed using semistructured interviews of hernia experts to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed, coded, and thematically analyzed. Results: A conceptual framework was synthesized based on literary sources (4 book chapters, 4 peer-reviewed articles, 3 online videos), 2 field observations, and interviews of 4 hernia experts [median 66 minutes (44–78)]. Subject matter experts practiced a median of 6.5 years (1.5–16) and have completed a median of 300 (60–500) TARs. After 5 rounds of inductive analysis, 80 subtasks, 86 potential errors, 36 cognitive behaviors, and 17 decision points were identified and categorized into 10 procedural steps (midline laparotomy, adhesiolysis, retrorectus dissection, etc.) and 9 fundamental principles: patient physiology and disease burden; tactical modification; tissue reconstruction and wound healing; task completion; choice of technique and instruments; safe planes and danger zones; exposure, ergonomics, environmental limitations; anticipation and forward planning; and tissue trauma and handling. Conclusion: This is the first study to define the key tasks, decisions, and cognitive behaviors that are essential to a successful TAR procedure.

Predictive factors for complexity in abdominal wall hernias: a literature scope review

“…A recurrent hernia is considered a risk factor for a new recurrence, given the pathogenesis of these injuries, which often involve individual issues 32 , 38 . Furthermore, correction surgery makes the quality of the tissues in the region less adequate, this happening because tissue dissection, mesh removal, fascial retraction, and debridement are factors that make the tissues more vulnerable and less adapted to surgical repair 10 , 32 , 39 .…”

“…A recurrent hernia is considered a risk factor for a new recurrence, given the pathogenesis of these injuries, which often involve individual issues 32,38 .…”

Análise dos fatores preditores de complexidade de hérnias da parede abdominal: uma Revisão de escopo da Literatura

“…Uma hérnia recorrente é considerada um fator de risco para uma nova recorrência, haja vista a patogênese dessas lesões que muitas vezes envolvem questões individuais 32,38 . Além disso, cirurgia de correção torna a qualidade dos tecidos na região menos adequada, isso acontece pois a dissecção tecidual, explantação de tela, retração fascial e desbridamento são fatores que tornam o tecido mais vulneráveis e menos adaptados ao reparo cirúrgico 10,32,39 .…”