Technical and Nontechnical Skills in Surgery: A Simulated Operating Room Environment Study
Abstract
Study design Observational simulation study. Objective The goal of this study was to investigate the relationship between technical and nontechnical skills (NTS) in a simulated surgical procedure. Summary of background data Although surgeons' technical and NTS during surgery are crucial determinants for clinical outcomes, little literature is available in spine surgery. Moreover, evidence regarding how surgeons' technical and NTS are related is limited. Methods A mixed-reality and full-scale simulated operating room environment was employed for the surgical team. Eleven surgeons performed the vertebroplasty procedure (VP). Technical skills (TS) were assessed using Objective Structured Assessment of Technical Skill scores and senior expert-evaluated VP outcome assessment. NTS were assessed with the Observational Teamwork Assessment for Surgery. Kendall-Tau-b tests were performed for correlations. We further controlled the influence of surgeons' experience (based on professional tenure and number of previous VPs performed). Result Surgeons' NTS correlated significantly with their technical performance (τ = 0.63; P = 0.006) and surgical outcome scores (τ = 0.60; P = 0.007). This association was attenuated when controlling for surgeons' experience. Conclusion Our results suggest that spine surgeons with higher levels of TS also apply better communication, leadership, and coordination behaviors during the procedure. Yet, the role of surgeons' experience needs further investigation…
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Outcomes after minimally invasive surgery are positively correlated with technical proficiency, experience, and procedural volume of the operator.
“It is well known that due to the aforementioned challenges, among others, outcomes after minimally invasive surgery are positively correlated with technical proficiency, experience, and procedural volume of the operator (Birkmeyer et al., 2013; Pfandler et al., 2019; Hafezi-Nejad et al., 2020; Foley and Hsu, 2021).”
From The Impact of Machine Learning on 2D/3D Registration for Image-Guided Interventions: A Systematic Review and Perspective (2021) · cites this paper as Pfandler et al., 2019
Cites
Cognitive load theory in health professional education: design principles and strategies
Van Merriënboer, J. J. G., & Sweller, J. (2010) · Medical Education · doi:10.1111/j.1365-2923.2009.03498.x · Cited by 1,511 · see citing works
Non-technical skills for surgeons in the operating room: A review of the literature
Yule, S., Flin, R. H., Paterson‐Brown, S., & Maran, N. (2006) · Surgery · doi:10.1016/j.surg.2005.06.017 · Cited by 762 · see citing works
Cheng, A., Kessler, D. O., MACKINNON, R. J., Chang, T. P., Nadkarni, V., Hunt, E. A., Duval‐Arnould, J., Lin, Y., Cook, D. A., Pusic, M. V., et al. (2016) · Advances in Simulation · doi:10.1186/s41077-016-0025-y · Cited by 552 · see citing works
Systematic review of skills transfer after surgical simulation-based training
Dawe, S. R., Pena, G. N., Windsor, J. A., Broeders, J. A. J. L., Cregan, P. C., Hewett, P. J., & Maddern, G. J. (2014) · British journal of surgery · doi:10.1002/bjs.9482 · Cited by 485 · see citing works
McCulloch, P. G., Mishra, A., Handa, A. I., Dale, T., Hirst, G., & Catchpole, K. C. (2009) · BMJ Quality & Safety · doi:10.1136/qshc.2008.032045 · Cited by 394 · see citing works
The Impact of Nontechnical Skills on Technical Performance in Surgery: A Systematic Review
Hull, L., Arora, S., Aggarwal, R. K., Darzi, A. W., Vincent, C. A., & Sevdalis, N. (2011) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2011.10.016 · Cited by 391 · see citing works
The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy
Mishra, A., Catchpole, K. C., Dale, T., & McCulloch, P. G. (2007) · Surgical Endoscopy · doi:10.1007/s00464-007-9346-1 · Cited by 268 · see citing works
Observational Teamwork Assessment for Surgery: Content Validation and Tool Refinement
Hull, L., Arora, S., Kassab, E. S., Kneebone, R. L., & Sevdalis, N. (2011) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2010.11.001 · Cited by 215 · see citing works
The Effects of Stress and Coping on Surgical Performance During Simulations
Wetzel, C. M., Black, S. A., Hanna, G. B., Athanasiou, T., Kneebone, R. L., Nestel, D., Wolfe, J. H. N., & Woloshynowych, M. (2009) · Annals of Surgery · doi:10.1097/sla.0b013e3181b3b2be · Cited by 208 · see citing works
JMASM9: Converting Kendall's Tau For Correlational Or Meta-Analytic Analyses
Walker, D. A. (2003) · Journal of Modern Applied Statistical Methods · doi:10.22237/jmasm/1067646360 · Cited by 208 · see citing works
Hatala, R. A., Cook, D. A., Brydges, R., & Hawkins, R. E. (2015) · Advances in Health Sciences Education · doi:10.1007/s10459-015-9593-1 · Cited by 177 · see citing works
Riem, N., Boet, S., Bould, M. D., Tavares, W., & Naik, V. N. (2012) · British Journal of Anaesthesia · doi:10.1093/bja/aes256 · Cited by 126 · see citing works
Krage, R., Zwaan, L., Len, L. T. S., Kolenbrander, M. W., van Groeningen, D., Loer, S. A., Wagner, C., & Schober, P. R. (2017) · Emergency Medicine Journal · doi:10.1136/emermed-2016-205754 · Cited by 124 · see citing works
Siu, J., Maran, N., & Paterson‐Brown, S. (2014) · The Surgeon · doi:10.1016/j.surge.2014.06.005 · Cited by 106 · see citing works
Anderson, D. D., Long, S., Thomas, G. W., Putnam, M. D., Bechtold, J. E., & Karam, M. D. (2015) · Clinical Orthopaedics and Related Research · doi:10.1007/s11999-015-4603-4 · Cited by 96 · see citing works
Non-technical skills in minimally invasive surgery teams: a systematic review
Gjeraa, K., Spanager, L., Konge, L., Petersen, R. H., & Østergaard, D. (2016) · Surgical Endoscopy · doi:10.1007/s00464-016-4890-1 · Cited by 94 · see citing works
Black, S. A., Nestel, D., Kneebone, R. L., & Wolfe, J. H. N. (2010) · British journal of surgery · doi:10.1002/bjs.6938 · Cited by 70 · see citing works
Brunckhorst, O., Shahid, S., Aydın, A., McIlhenny, C., Khan, S., Raza, S. J., Sahai, A., Brewin, J., Bello, F., Kneebone, R. L., et al. (2014) · Surgical Endoscopy · doi:10.1007/s00464-014-3996-6 · Cited by 65 · see citing works
Brunckhorst, O., Shahid, S., Aydın, A., Khan, S., McIlhenny, C., Brewin, J., Sahai, A., Bello, F., Kneebone, R. L., Khan, M. S., et al. (2015) · Journal of surgical education · doi:10.1016/j.jsurg.2015.04.002 · Cited by 64 · see citing works
Lee, J. Y., Mucksavage, P., Canales, C., McDougall, E. M., & Lin, S. (2012) · The Journal of Urology · doi:10.1016/j.juro.2011.11.106 · Cited by 58 · see citing works
Non-technical skills of surgical trainees and experienced surgeons
Gostlow, H. C., Marlow, N. E., Thomas, M. J. W., Hewett, P. J., Kiermeier, A., Babidge, W., Altree, M., Pena, G. N., & Maddern, G. J. (2017) · British journal of surgery · doi:10.1002/bjs.10493 · Cited by 46 · see citing works
Can Simulated Team Tasks be Used to Improve Nontechnical Skills in the Operating Room?
Rao, R., Dumon, K. R., Neylan, C. J., Morris, J. B., Riddle, E. W., Sensenig, R., Park, Y., Williams, N. N., Dempsey, D. T., & Brooks, A. D. (2016) · Journal of surgical education · doi:10.1016/j.jsurg.2016.06.004 · Cited by 44 · see citing works
The Role of Mixed Reality Simulation for Surgical Training in Spine
Coelho, G., & Defino, H. L. A. (2018) · Spine · doi:10.1097/brs.0000000000002856 · Cited by 42 · see citing works
Are Low Patient Satisfaction Scores Always Due to the Provider?
Bible, J. E., Shau, D. N., Kay, H. F., Cheng, J. S., Aaronson, O. S., & Devin, C. J. (2016) · Spine · doi:10.1097/brs.0000000000001453 · Cited by 39 · see citing works
Panesar, S. S., Carson‐Stevens, A., Mann, B., Bhandari, M., & Madhok, R. (2012) · BMC Musculoskeletal Disorders · doi:10.1186/1471-2474-13-93 · Cited by 34 · see citing works
A radiation-free mixed-reality training environment and assessment concept for C-arm-based surgery
Stefan, P., Habert, S., Winkler, A., Lazarovici, M., Fürmetz, J., Eck, U., & Navab, N. (2018) · International Journal of Computer Assisted Radiology and Surgery · doi:10.1007/s11548-018-1807-6 · Cited by 26 · see citing works
Self-citationThe Effectiveness of Bioskills Training for Simulated Open Lumbar Laminectomy
Boody, B. S., Rosenthal, B. D., Jenkins, T. J., Patel, A. A., Savage, J. W., & Hsu, W. K. (2017) · Global Spine Journal · doi:10.1177/2192568217703337 · Cited by 21 · see citing works
Non-technical skills of surgery residents: does experiential learning lead to competence?
Dedy, N. J., Zevin, B., Bonrath, E. M., & Grantcharov, T. (2013) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2013.07.266 · Cited by 7 · see citing works
Pfandler, M., Stefan, P., Wucherer, P., Lazarovici, M., & Weigl, M. (2018) · Advances in Simulation · doi:10.1186/s41077-018-0077-2 · Cited by 4 · see citing works
Self-citation
Flagged first, then by citations
Cited by
Sorted by citations
Chen, J., Liu, Y., Wei, S., Bian, Z., Subramanian, S., Carass, A., Prince, J. L., & Du, Y. (2024) · Medical Image Analysis · doi:10.1016/j.media.2024.103385 · Cited by 188 · see citing works
Unberath, M., Gao, C., Hu, Y., Judish, M., Taylor, R. H., Armand, M., & Grupp, R. (2021) · Frontiers in Robotics and AI · doi:10.3389/frobt.2021.716007 · Cited by 102 · see citing works
“positively correlated with technical proficiency, experience, and procedural volume of the operator [1, 2, 3, 4].”
BackgroundLocal feature matching using deep learning: A survey
Xu, S., Chen, S., Xu, R., Wang, C., Lu, P., & Guo, L. (2024) · Information Fusion · doi:10.1016/j.inffus.2024.102344 · Cited by 107 · see citing works
Schreyer, J., Koch, A., Herlemann, A., Becker, A. J., Schlenker, B., Catchpole, K. C., & Weigl, M. (2021) · Surgical Endoscopy · doi:10.1007/s00464-021-08474-2 · Cited by 40 · see citing works
Self-citationEvaluating how residents talk and what it means for surgical performance in the simulation lab
D’Angelo, A.-L. D., Ruis, A. R., Collier, W., Shaffer, D. W., & Pugh, C. M. (2020) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2020.02.016 · Cited by 20 · see citing works
Stefan, P., Pfandler, M., Kullmann, A., Eck, U., Koch, A., Mehren, C., von der Heide, A., Weidert, S., Fürmetz, J., Euler, E., et al. (2023) · BMJ Surgery Interventions & Health Technologies · doi:10.1136/bmjsit-2022-000135 · Cited by 7 · see citing works
Self-citationOpfermann, J. D., Killeen, B. D., Bailey, C. R., Khan, M., Uneri, A., Suzuki, K., Armand, M., Hui, F. K., Krieger, A., & Unberath, M. (2021) · IEEE International Conference on Bioinformatics and Bioengineering (BIBE) · doi:10.1109/bibe52308.2021.9635356 · Cited by 6 · see citing works
Anatomy Scholars Program for Medical Students Entering a Surgical Residency
Gongola, A., Gowen, J. T., Reif, R., Thrush, C. R., Newhart, H., Peckham, M., Schwartz, Z., Davies, D., & Kimbrough, M. K. (2021) · Medical Science Educator · doi:10.1007/s40670-021-01352-5 · Cited by 5 · see citing works
Mehren, C., Korb, W., Fenyöházi, E., Iacovazzi, D., Vera, L. E. B., & Mayer, M. H. (2020) · Global Spine Journal · doi:10.1177/2192568220917369 · Cited by 5 · see citing works
Self-citationMeasuring Spine Surgeon Performance
McMahan, S. R., Courtois, E. C., Satin, A. M., Guyer, R. D., Wilson, B. A., Robinson, K. T., & Ohnmeiss, D. D. (2025) · Spine · doi:10.1097/brs.0000000000005451 · Cited by 3 · see citing works
de Laurentis, C., Pirillo, D., Cristofori, A. D., Versace, A., Calloni, T., Trezza, A., Villa, V., Alberti, L., Baldo, A., Nicolosi, F., et al. (2024) · Frontiers in Surgery · doi:10.3389/fsurg.2024.1386887 · Cited by 3 · see citing works
Hwang, W., Groom, J. A., Kardong‐Edgren, S., & Simmons, V. C. (2024) · Clinical Simulation in Nursing · doi:10.1016/j.ecns.2024.101641 · Cited by 2 · see citing works
Toward real-time alignment of 3D CT and 2D X-ray with multi-stage CNNs
Facente, F., Billot, B., Gopalakrishnan, V., Kattel, M., Wei, W., Golland, P., Delingette, H., Ayache, N., & Berthet-Rayne, P. (2026) · Computer Assisted Surgery · doi:10.1080/24699322.2026.2684372 · Cited by 1 · see citing works
Mixed and Augmented Reality Simulation for Minimally Invasive Spine Surgery Education
Weidert, S., & Stefan, P. (2022) · Springer eBooks · doi:10.1007/978-981-19-0175-1_41 · Cited by 1 · see citing works
Self-citationZiaei-Darounkolaei, N., Kiasary, S. M. S. M., Behzadi, A., Mousavi, N. N., & Ferdowsi, S. M. (2023) · Frontiers in Veterinary Science · doi:10.3389/fvets.2023.1210089 · Cited by 1 · see citing works
Outcome-relevante Faktoren in der Wirbelsäulenchirurgie
Spiegl, U. J. A., Josten, C., & Heyde, C. (2020) · Die Wirbelsäule · doi:10.1055/a-0968-7160
Trabajo en equipo en el área quirúrgica
Rondón-Arreaza, G. A., Palermo, M. V., Ordaz-Cedeño, K. G., Sequera, R., Cesar-Rengifo, C. J., Rodríguez, E. S. H., & Mendoza, S. (2025) · Revista Colombiana de Cirugía · doi:10.30944/20117582.2792
Siddiqui, Z. K., Lewis, C., Myatt, A., Jayasuriya, R. L., Balachandar, V., Herrick, T., & Tomlinson, J. E. (2025) · BMC Medical Education · doi:10.1186/s12909-025-07740-4
Multi-stage CNN for Fast Registration of 3D Preoperative CTs to 2D Intraoperative X-Rays
Facente, F., Billot, B., Gopalakrishnan, V., Kattel, M., Wei, W., Golland, P., Delingette, H., Ayache, N., & Berthet-Rayne, P. (2026) · Lecture notes in computer science · doi:10.1007/978-3-032-09784-2_14
Gulnaz, N., Soomro, F. H., Nazir, I., Ansar, M., & Arshad, R. (2026) · BMC Medical Education · doi:10.1186/s12909-026-09486-z
Koike, D., Kato, H., Kajino, Y., Kondo, Y., Ito, M., Horiguchi, A., & Nagao, Y. (2026) · Journal of Surgical Research · doi:10.1016/j.jss.2026.05.071
Healthcare Professionals’ Communication Attitudes in Intensive Care Units: A Qualitative Study
Delibalta, B., Üçüncüoğlu, M., Güner, Y., Dilbaz, A. D., & Lazarovici, M. (2026) · Archives of Current Medical Research · doi:10.47482/acmr.1895611
Self-citation
- Authors
- Pfandler, M., Stefan, P., Mehren, C., Lazarovici, M., & Weigl, M.
- Affiliations
- ORCID (US)
- Technical University of Munich (DE)
- Paracelsus Medical University (AT)
- Institut für Notfallmedizin und Medizinmanagement (DE)
- Corresponding author
- Pfandler, Michael
- Venue
- Spine
- Published
- 2019-12-01
- Volume
- 44
- Issue
- 23
- Pages
- E1396-E1400
- ISSN
- 0362-2436 (ISSN-L)
- 1528-1159
- OpenAlex
- W2964853206
- Cited by
- 22
- References
- 29
- Citations by year
- 2026: 5 · 2025: 3 · 2024: 4 · 2023: 2 · 2022: 1 · 2021: 4 · 2020: 3
- FWCI
- 1.91
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Spine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Surgical Simulation and Training
- Health Sciences › Medicine › Physiology › Simulation-Based Education in Healthcare
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Innovations in Medical Education
- Keywords
- non-technical skills, technical skills, spinal surgery, vertebroplasty, surgical simulation, teamwork, leadership, communication, surgical outcomes, surgeon experience, mixed reality simulation
- MeSH terms
- Clinical Competence, Communication, Humans, Leadership, Operating Rooms, Patient Care Team, Pilot Projects, Surgeons
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