Measuring the Impact of an Exoscopic Camera System on Learner Mental Workload in Vaginal Surgery

INTRODUCTION: The decreasing rates of vaginal hysterectomy are well documented and visualization difficulties in vaginal surgery may contribute to this decline. While new technologies introduced to the operating room have the opportunity to improve visualization, there is risk of increased workload and job stress. OBJECTIVE: To measure the impact of an exoscopic camera system during vaginal surgery on the workload and learning experience of obstetrics and gynecology residents and fellows. METHODS: Obstetrics and gynecology residents and fellows at 2 tertiary referral centers were surveyed after participating in vaginal hysterectomies with and without the use of an exoscopic camera system. The primary outcome was workload measured using the NASA-TLX scale. The NASA-TLX scale is a validated tool that measures workload across six dimensions: mental demand, physical demand, temporal demand, effort, performance, and frustration level. The secondary outcome was trainee experience, measured across seven areas: visualization, confidence, intrusion, engagement, knowledge application, skill-building, and procedural flow (Table 1). The Welch’s two-sample t-test was used to compare NASA-TLX mean (SD) scores between groups for the entire cohort. For paired data, where a learner participated in one surgery with and one without the camera, median scores were compared using the Wilcoxon signed-rank test and Cliff’s Delta (ΔCliff’s) estimated the effect size. Prior surgical studies suggest a mean total NASA-TLX score of 50 (SD 3.7). To demonstrate a five-point (10%) decrease with alpha = 5% and 80% power, a sample size of 10 paired learners was needed. Data were analyzed and graphs generated in RStudio. RESULTS: From June 2021 to January 2024, 39 surveys were completed by 30 trainees: 21 with the exoscopic camera and 18 without. There were 10 trainees with paired survey data. The overall mean NASA-TLX workload scores did not differ between learners who did and did not utilize the camera system (mean 40.4 [SD 14.9] with camera vs. 47.5 [SD 21.5] without; p=0.14). Use of the exoscopic camera was associated with a lower physical demand score (mean 39.9 [SD 41.3]) than without (mean 53.1 [SD 19.2], p=0.05), but no differences were observed for mental demand, temporal demand, effort, performance or frustration level (p>0.05). Among the paired data (n=10 trainees), there were no differences in the overall median NASA-TLX score (47.4 versus 49.3; p=0.28) or the six dimension scores between groups (Figure 1). Seven out of ten trainees had decreased overall NASA-TLX scores with use of the camera (mediandiff=−9.07), while 3 increased (mediandiff=+10.2) (Figure 2). Exoscopic camera use had a small positive effect on procedure visualization (ΔCliff’s=0.26) and perceived value of the case for surgical skills (ΔCliff’s=0.29). There was moderate effect of the camera on procedure flow (ΔCliff’s=0.46) and large effect on trainee engagement (ΔCliff’s=0.5). There was no effect on application of anatomy (ΔCliff’s=0.04), confidence in anticipation (ΔCliff’s=0.06), or feeling “in the way” (ΔCliff’s=−0.01). CONCLUSIONS: In this cohort study comparing trainee experience in vaginal hysterectomy with and without the use of an exoscopic camera system, use of this new technology improved trainee engagement without negatively impacting workload. More research is warranted to optimize use of visual technology for training in vaginal surgery.