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Heart rate variability: an objective measure of mental stress in surgical simulation

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Global Surgical Education - Journal of the Association for Surgical Education Aims and scope Submit manuscript

A Letter to the Editor to this article was published on 18 June 2024

A Letter to the Editor to this article was published on 18 June 2024

Abstract

Purpose

Highly stressful conditions in the operating room are associated with an increased risk of surgical adverse events and worse patient outcomes. Identifying and measuring mental stress in the surgical setting can guide our intervention efforts. The aim of this study was to evaluate the feasibility of heart rate variability (HRV) monitoring as an objective measure of mental stress and its correlation with expertise level in surgical simulation.

Methods

General surgery residents and faculty participated in a laparoscopic hiatal hernia repair simulation on porcine and synthetic models. Whole-procedure electrocardiographic (ECG) data was recorded, and manual artifact correction was performed. On power spectral density analysis, we computed the low-frequency/high-frequency (LF/HF) ratio, considered a surrogate for stress and mental strain. Mental workload was also subjectively assessed using the NASA-TLX rating scale.

Results

We recruited 37 participants: 18 novice, 14 intermediate, and 5 expert surgeons. When comparing the first to the second half of the procedure, the LF/HF ratio (stress level) relatively increased in novices (+ 23% for fundoplication, + 19% for crural repair), decreased in intermediates (− 11% and − 8%, respectively), and decreased in experts (− 40%, − 30%) (p = 0.001, p = 0.009). Pairwise comparison showed significant differences in stress level between novices and experts in both simulation models. NASA-TLX revealed higher mental and physical load among novice trainees, while experts reported greater satisfaction with their performance.

Conclusions

HRV monitoring in surgical simulation is a feasible and effective method to objectively evaluate mental stress and correlate it with the level of surgical expertise. We have shown that the relative change in LF/HF ratio can adequately distinguish between novice and expert surgeons. Our study supports the incorporation of HRV monitoring in surgical simulators to complement objective assessment of technical skills.

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Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

We appreciate the support of the UT Southwestern Simulation Center. We also thank Dave Primm of the UT Southwestern Department of Surgery for help in editing this article.

Funding

This work was supported by the National Institute of Health/National Institute of Biomedical Imaging and Bioengineering grant #R01EB025247.

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Authors and Affiliations

  1. Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, USA

    Emile Farah, Alexis Desir, Carolina Marques, Shruti R. Hegde, Andres Abreu, Patricio M. Polanco, Carla Holcomb, Daniel J. Scott & Ganesh Sankaranarayanan

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Correspondence to Ganesh Sankaranarayanan.

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Drs. Emile Farah, Alexis Desir, Carolina Marques, Shruti Hegde, Carla Holcomb, Andres Abreu, Patricio Polanco, Daniel Scott, and Ganesh Sankaranarayanan have no other conflict of interest or financial ties to disclose that are directly or indirectly related to the work submitted for publication.

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Fig. 8
figure 8

The National Aeronautics and Space Administration Task Load Index (NASA-TLX) questionnaire (instructions: please place an “X” along each scale at the point that best indicates your experience with the display configuration)

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Farah, E., Desir, A., Marques, C. et al. Heart rate variability: an objective measure of mental stress in surgical simulation. Global Surg Educ 3, 25 (2024). https://doi.org/10.1007/s44186-023-00220-7

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