Purpose: Despite low complication rates, deep inferior epigastric perforator flaps (DIEP) have steep learning curves. While operating time and re-exploration rates significantly decrease with experience, differences in cognitive and technical processes between a novice and expert are not fully understood. We aim to: (1) define the tasks, decisions, and potential errors in a DIEP flap procedure and (2) analyze the expert cognitive behaviors involved.
Methods: Cognitive task analysis was performed using a semi-structured interview of a subject matter expert to explore the thoughts and behaviors that exemplify optimal performance of this procedure. The interview was supplemented with additional resources and coded based on a modification of the framework by Grover.
Results: We created a preliminary master task list including 227 subtasks, 61 potential errors, 71 technical tips, and 26 decisions, categorized into seven major tasks: pre-op workup, procedural preparation, flap dissection, chest preparation, revascularization, flap inset, and abdominal closure (Figure 1). Of the 10 cognitive behaviors identified, atraumatic tissue handling was the most prevalent. Revascularization was the major task with the highest number of subtasks, while potential errors were highest during chest preparation.
Conclusions: Our preliminary task list highlights critical areas for decision-making and error avoidance, as well as numerous technical tips that allow experts to perform DIEP flaps with optimal results. Ongoing work includes creating a visual framework for education and assessment.
