Adaptive learning for safe cholecystectomy training: effects on knowledge acquisition and guideline-based reasoning in surgical trainees

Adaptive learning for safe cholecystectomy training: effects on knowledge acquisition and guideline-based reasoning in surgical trainees | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Adaptive learning for safe cholecystectomy training: effects on knowledge acquisition and guideline-based reasoning in surgical trainees Dimitrios Chatziisaak, Moritz Sparn, Pascal Burri, Martina Vitz, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9112702/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Safe laparoscopic cholecystectomy requires not only technical proficiency but also structured clinical reasoning and guideline-based decision-making. Adaptive learning platforms have emerged as technology-enhanced educational tools designed to personalize instruction and reinforce areas of uncertainty. However, evidence regarding their role in supporting clinical reasoning in surgical education remains limited. This study evaluated the educational impact of an adaptive pre-course learning module on knowledge acquisition in safe laparoscopic cholecystectomy within a structured surgical training course. Methods We conducted a prospective non-randomized educational intervention during the 42nd Annual Davos GI Course in 2025. Surgical trainees enrolled in the basic curriculum were invited to complete an optional adaptive learning module on safe laparoscopic cholecystectomy prior to course participation. Knowledge performance was assessed using pre- and post-course questionnaires. The primary outcome was the change in total percentage knowledge score (ΔTotal %). Secondary outcomes included domain-specific knowledge changes, exploratory item-level response differences, and associations between self-reported confidence and knowledge performance. Results Seventy-nine surgical trainees participated, including 57 in the control group and 22 who completed the adaptive learning module. Baseline demographic and professional characteristics were comparable between groups. Median total knowledge improvement was 5% [0–15%] in the control group and 7.5% [0–22.5%] in the intervention group, with no statistically significant between-group difference (p = 0.590). Domain-specific improvements were similar across groups. In exploratory item-level analyses, three post-course questions requiring guideline-based clinical reasoning demonstrated higher response accuracy in the intervention group. Overall post-course performance showed high correct response rates across most questionnaire items. Conclusions Adaptive pre-course learning did not result in greater overall knowledge gains compared with standard instruction alone. However, exploratory findings suggest that adaptive learning may support selected aspects of guideline-based clinical reasoning. Adaptive modules may therefore represent a useful complementary preparatory strategy within structured surgical training programs. Adaptive learning surgical education safe cholecystectomy clinical reasoning technology-enhanced learning competency-based education Figures Figure 1 Figure 2 Background Minimally invasive cholecystectomy is among the most frequently performed surgical procedures worldwide and constitutes a foundational benchmark in surgical training ( 1 ). Despite its routine nature and the widespread dissemination of safety standards, clinically relevant complications - including bile duct injuries and severe inflammatory sequelae - continue to occur ( 2 ). These adverse events often reflect not only technical challenges but also cognitive gaps in risk stratification, severity assessment, and intraoperative decision-making ( 3 , 4 ). Accordingly, contemporary surgical education increasingly emphasizes not only psychomotor proficiency but also structured clinical reasoning and guideline-based judgment. In parallel with the shift toward competency-based curricula, technology-enhanced learning strategies have expanded substantially, including virtual simulation training, adaptive learning platforms, and artificial intelligence-driven instructional systems ( 4 , 5 ). Virtual simulation training has demonstrated benefits in improving operative performance metrics and technical skills in laparoscopic procedures, including cholecystectomy ( 6 ). However, simulation-based training predominantly targets psychomotor skill acquisition and may insufficiently address higher-order cognitive processes such as guideline integration, dynamic risk assessment, and escalation strategies. Adaptive learning represents an instructional paradigm designed to tailor educational content to the learner’s evolving level of understanding through continuous assessment and individualized feedback ( 7 ). Such approaches align with conceptual frameworks including the “Master Adaptive Learner” model, which emphasizes metacognition, self-regulated learning, and adaptive expertise ( 8 ). By dynamically reinforcing areas of uncertainty and promoting deeper conceptual integration, adaptive learning may be particularly suited to surgical training, where safe operative practice depends on the integration of evidence-based guidelines with context-sensitive clinical judgment. Nevertheless, empirical evidence evaluating adaptive learning specifically in surgical decision-making contexts remains limited. To address this gap, we implemented an adaptive learning module focused on safe laparoscopic cholecystectomy, grounded in the “Tokyo Guidelines 2018” (TG18) and “SAGES Safe Cholecystectomy” principles ( 9 , 10 ). The module emphasized severity grading, escalation pathways, and intraoperative risk recognition. We hypothesized that completion of this adaptive pre-course module would enhance knowledge acquisition during a structured surgical training course and, in particular, improve performance on items requiring higher-order guideline-based clinical reasoning compared with standard instruction alone. The aim of this study was to evaluate the educational impact of this adaptive pre-course intervention on overall knowledge gain and guideline-based clinical reasoning in a cohort of surgical trainees. Methods Study Design and Setting This study was designed as a prospective, non-randomized educational intervention conducted during the 42nd Annual Davos GI Course in 2025 ( www.davoscourse.ch ). The study followed a predefined PICO framework. The population consisted of surgical trainees enrolled in the basic training curriculum of the course. The intervention was completion of an adaptive learning module on safe laparoscopic cholecystectomy prior to course participation. The comparator was participation in the standard course curriculum without exposure to the adaptive module. Knowledge performance before and after course participation served as the outcome measure. Participants, Baseline Assessment, and Group Allocation All trainees enrolled in the basic training track of the 2025 Davos GI Course were eligible for participation. Study participation required completion of both the pre-course and post-course knowledge assessments. Eligibility criteria for the basic curriculum included less than three years of surgical training and experience of fewer than twenty appendectomies or ten cholecystectomies. No exclusion criteria were applied. No formal a priori sample size calculation was performed, as the study was conducted within the fixed cohort of course participants. Prior to administration of the pre-course questionnaire and before any educational exposure, participants completed a structured baseline survey capturing demographic and professional characteristics, including year of birth, gender, handedness, year of medical degree, residency year, and country of practice. Participants reported prior experience in minimally invasive appendectomy, cholecystectomy, colorectal, bariatric, and hernia surgery, including entrustable professional activity (EPA) levels where applicable ( 11 ). Self-assessed minimally invasive competence was recorded using a 10-point Likert scale, and additional items assessed perceived laparoscopic dexterity, tissue handling, operative flow, time–motion efficiency, and autonomy. Baseline data were collected to allow assessment of group equivalence and to minimize measurement bias. An optional adaptive learning module was offered to all participants prior to course commencement. Completion of the module was voluntary and not linked to course certification. Participants received electronic invitations and reminder notifications before the course. Trainees who completed the adaptive module constituted the intervention group, whereas those who did not participate formed the control group. Given the self-selected allocation, baseline equivalence between groups was systematically evaluated across demographic, experiential, and knowledge variables to address potential selection bias. All participants attended the structured in-person Basic curriculum of the Davos GI Course, which included didactic lectures, case-based discussions, and simulation-based laparoscopic training sessions (Box trainer exercises). The curriculum was identical for both groups. Adaptive Learning Intervention The adaptive learning module was developed using the Area9 Lyceum platform (Area9 Lyceum, Copenhagen, Denmark). The module focused on safe laparoscopic cholecystectomy and was aligned with the Tokyo Guidelines 2018 (TG18) and SAGES Safe Cholecystectomy principles ( 9 , 10 ). Content was organized into three domains: ( 1 ) preoperative assessment and severity grading, ( 2 ) intraoperative safety strategies including the Critical View of Safety and bailout techniques, and ( 3 ) postoperative complication recognition and management. The platform employs an adaptive algorithm that dynamically adjusts item difficulty, sequencing, and feedback based on learner responses. Learners received immediate explanatory feedback and were required to demonstrate mastery of individual concepts before progression. The module was completed asynchronously prior to course participation. Completion data were recorded automatically by the platform. Outcomes The primary outcome was the change in total percentage knowledge score (ΔTotal %) from pre-course to post-course assessment. Secondary outcomes included domain-specific knowledge changes, item-level response differences between groups, and associations between self-reported confidence and knowledge performance. Questionnaire Development and Structure The pre-course and post-course knowledge assessments were specifically developed for this study. The questionnaires were designed based on the Tokyo Guidelines 2018 (TG18) and SAGES Safe Cholecystectomy principles to evaluate both factual knowledge and guideline-based clinical reasoning across preoperative, intraoperative, and postoperative domains. The pre-course questionnaire consisted of two components: a baseline survey capturing demographic and professional characteristics, prior surgical experience, and self-assessed competence, and a multiple-choice knowledge assessment focusing on laparoscopic cholecystectomy (Supplementary File 1). The post-course questionnaire consisted of a multiple-choice assessment with conceptually aligned items addressing the same domains, allowing evaluation of knowledge acquisition following course participation (Supplementary File 2). Statistical Analysis Categorical variables were summarized as frequencies and percentages and compared between groups using Pearson’s χ² test or Fisher’s exact test when appropriate ( 12 , 13 ). Continuous variables were assessed for normality using the Shapiro–Wilk test and are reported as mean ± standard deviation for normally distributed data or median with interquartile range for non-normal distributions ( 14 ). Because percentage knowledge scores were not normally distributed, nonparametric tests were predominantly applied. Baseline comparisons between the control and intervention groups were conducted using independent-samples t-tests for normally distributed variables and Mann–Whitney U tests for non-normal continuous variables ( 15 ). Item-level response distributions were analyzed separately for pre-course and post-course questionnaires using χ² tests to identify topic-specific differences between groups. Between-group comparisons of phase-level and total percentage scores at each time point were performed using Mann–Whitney U tests. Within-group differences across operative phases were assessed using Friedman’s test for related samples ( 16 ). When significant, post hoc comparisons were interpreted descriptively with Bonferroni-adjusted thresholds ( 17 ). To isolate the effect of the adaptive learning intervention beyond general course-related improvement, an individual-level Difference-in-Differences (DiD) approach was applied. For each participant, change scores (Δ = post-course percentage − pre-course percentage) were calculated for total and phase-specific knowledge domains. Between-group comparisons of Δ values were performed using Mann–Whitney U tests or independent-samples t-tests when normality assumptions were met. Mixed-effects modeling was not applied because the pre- and post-course questionnaires contained different but conceptually aligned items. Associations between self-confidence and knowledge performance were assessed using Spearman’s rank correlation coefficients, and knowledge scores were compared across categorized confidence levels using Mann–Whitney U tests. To explore predictors of knowledge gain (ΔTotal %), a generalized linear model was constructed including self-confidence level, group assignment, year of birth, and prior minimally invasive procedural experience as independent variables. Regression coefficients, 95% confidence intervals, and p-values were reported, and model fit was evaluated using omnibus χ² statistics and information criteria. All statistical tests were two-tailed, and a p-value < 0.05 was considered statistically significant. Analyses were performed using IBM SPSS Statistics version 27.0 (IBM Corp., Armonk, NY, USA). Given the exploratory nature of item-level analyses, findings should be interpreted cautiously in the context of multiple comparisons. Ethics approval and consent to participate All methods were carried out in accordance with relevant guidelines and regulations. This study was conducted in accordance with the Declaration of Helsinki and the Swiss Federal Act on Research involving Human Beings (Human Research Act, HRA; SR 810.30). According to Swiss law and guidance from Swissethics, research involving exclusively irreversibly anonymized data does not fall within the scope of the Human Research Act and therefore does not require approval from a cantonal ethics committee. The competent cantonal ethics committee (Ethikkommission Ostschweiz, EKOS) confirmed that the present study does not fall under the Human Research Act and that no formal ethical approval was required. Participation was voluntary, and all participants provided written informed consent prior to inclusion in the study. Results Participant Characteristics and Baseline Equivalence A total of 79 surgical trainees participated in the study, including 57 in the control group and 22 in the intervention group. All participants completed both pre-course and post-course assessments. Baseline demographic and professional characteristics did not differ significantly between groups. The median year of birth was 1996 in both cohorts (Control: 1996 [IQR 1994–1997]; Intervention: 1996 [IQR 1992–1997]; U = 563, p = 0.480). Gender distribution was comparable (43.9% vs. 45.5% male; χ²(1) = 0.16, p = 0.898), as were handedness, country of practice, and year of medical degree (all p > 0.05). Most participants were early-stage trainees, with 71.9% of the control group and 86.4% of the intervention group in the first or second year of residency (χ²(4) = 2.175, p = 0.704) (Table 1). Primary Outcome: Change in Total Knowledge Score (ΔTotal %) Individual change scores (Δ = post − pre) were calculated to assess the primary outcome of total knowledge gain. Median total knowledge improvement was 5% [0–15%] in the control group and 7.5% [0–22.5%] in the intervention group (U = 431, p = 0.590). Between-group comparisons of change scores did not demonstrate a statistically significant difference (Figure 2). Phase-specific improvements were comparable between groups (ΔPreoperative: U = 447, p = 0.752; ΔIntraoperative: U = 424, p = 0.523; ΔPostoperative: U = 429, p = 0.560). Secondary Outcomes Phase-Level Knowledge Performance Pre-Course Comparison At baseline, median total percentage scores were identical between groups (Control: 75% [70–80%]; Intervention: 75% [70–83%]; U = 456, p = 0.846). Phase-level analysis revealed no differences in preoperative (U = 403.5, p = 0.349) or postoperative domains (U = 397.5, p = 0.232) (Figure 1). Post-Course Comparison After course completion, both groups demonstrated improved performance. Median total scores increased to 85% in both cohorts (Control: 85% [75–90%]; Intervention: 85% [78–95%]; U = 420.5, p = 0.493). No statistically significant between-group differences were observed in preoperative (U = 435.5, p = 0.630) or intraoperative (U = 367.5, p = 0.115) domains. A difference approaching statistical significance was observed in the postoperative domain (U = 348.5, p = 0.06), with higher median scores in the intervention group (Figure 1). Within-Group Phase Comparisons Before course participation, both groups demonstrated statistically significant differences across operative phases. In the control group, Friedman’s test showed χ²(2) = 11.756 (p = 0.003), with higher scores in the postoperative phase compared with preoperative and intraoperative phases. Similarly, in the intervention group, χ²(2) = 17.360 (p < 0.001), with postoperative knowledge highest. After course completion, phase differences were no longer statistically significant in either group (Control: χ²(2) = 4.068, p = 0.131; Intervention: χ²(2) = 5.463, p = 0.065), indicating a more homogeneous distribution of knowledge across operative domains. Item-Level Knowledge Assessment Pre-Course Questionnaire No statistically significant differences were observed between groups across any pre-course questionnaire items (all p > 0.05). Both groups demonstrated strong performance in foundational diagnostic and intraoperative safety concepts, including first-line imaging modality and identification of the Critical View of Safety. Lower accuracy was observed in items requiring severity stratification and complex management decisions, particularly those related to TG18 grading and management of severe sepsis. These patterns were consistent across both groups, indicating shared conceptual difficulty prior to the educational intervention. Post-Course Questionnaire Following course participation, overall accuracy improved in both groups. Most items demonstrated high correct response rates (>85%) across both cohorts. In exploratory item-level analyses, three post-course items showed statistically significant between-group differences: a) Identification of TG18 Grade III (severe) complications (χ²(3) = 8.183, p = 0.042). b) Recognition that TG18 Grade III mandates ICU admission (χ²(2) = 5.365, p = 0.021). c) Identification of predictors of difficult laparoscopic cholecystectomy (χ²(3) = 15.606, p = 0.001). In all three cases, the intervention group demonstrated higher response accuracy compared with controls. All other items, including those related to antibiotic management and intraoperative safety strategies, showed no statistically significant differences, with both groups achieving near-ceiling performance (Table 2). Self-Confidence and Knowledge Performance No significant correlation was observed between baseline self-confidence and pre-course total knowledge score (Spearman r = 0.015, p = 0.907). This lack of association persisted when analyzed separately by group. When categorized into low and medium confidence levels, no differences were observed in baseline performance. Post-course, participants with medium confidence demonstrated higher total scores (U = 336.5, p = 0.033) and higher preoperative domain scores (U = 324.5, p = 0.020). However, change scores (Δ) did not differ significantly between confidence groups. Multivariable Analysis A generalized linear model was constructed to identify predictors of knowledge gain (ΔTotal %). The overall generalized linear model did not demonstrate statistical significance (Omnibus χ²(11) = 11.65, p = 0.39), indicating limited explanatory power. Group assignment was not associated with knowledge gain (p = 0.83). Self-confidence levels showed a negative association with improvement at lower levels (p values between 0.019 and 0.046), whereas age and prior procedural experience were not significant predictors (all p > 0.15) (Table 3). Discussion This prospective educational intervention study evaluated the impact of an adaptive learning module on knowledge acquisition in safe laparoscopic cholecystectomy within a structured surgical training course. Overall knowledge gains did not differ significantly between trainees who completed the adaptive module and those who participated in the standard curriculum alone. However, exploratory item-level analyses demonstrated higher accuracy in the intervention group for selected questions requiring guideline-based clinical reasoning related to severity grading, ICU indication, and predictors of operative difficulty. These findings suggest that adaptive learning may influence specific aspects of clinical reasoning even when overall knowledge gains remain comparable. The absence of a significant difference in the primary outcome indicates that short pre-course exposure to adaptive learning does not necessarily produce measurable increases in aggregate knowledge scores in a cohort undergoing intensive in-person instruction. The Davos GI Course provides a highly structured curriculum with lectures, case discussions, and simulation-based training, which likely contributes substantially to knowledge acquisition across participants. In this context, the adaptive module may have functioned primarily as a preparatory tool rather than an independent driver of overall score improvement. Nevertheless, the observed differences in selected post-course items are noteworthy. These questions required integration of multiple clinical variables and application of guideline-based reasoning rather than recall of isolated facts. Such tasks correspond to higher levels of cognitive processing within educational frameworks such as Bloom’s taxonomy. Adaptive learning systems are designed to identify individual knowledge gaps and reinforce areas of uncertainty through repeated exposure and targeted feedback (7,18,19). It is therefore plausible that the adaptive module supported deeper conceptual integration in areas where baseline understanding was limited. The pattern of findings may also reflect ceiling effects in several domains of the knowledge assessment. After course completion, both groups achieved high median scores and near-ceiling performance in many items related to fundamental surgical principles. In such situations, improvements in higher-order reasoning may be more difficult to detect through aggregate percentage scores. Similar observations have been reported in educational research evaluating technology-enhanced learning tools, where adaptive systems influence the structure and depth of knowledge rather than simply increasing total scores (20). An additional observation was the lack of correlation between baseline self-confidence and objective knowledge performance. This finding is consistent with previous literature demonstrating that self-perceived competence does not necessarily reflect actual knowledge or decision-making ability (21). Interestingly, lower self-confidence levels were associated with greater measured improvement in the multivariable model, suggesting that trainees who initially perceived themselves as less confident may have benefited more from structured learning opportunities. From an educational perspective, these findings support the potential role of adaptive learning as a complementary preparatory strategy within competency-based surgical curricula. Rather than replacing traditional instruction, adaptive modules may help prime learners for in-person training by reinforcing guideline-based frameworks and highlighting areas of uncertainty prior to course participation. Several limitations should be considered when interpreting these results. First, the study was conducted in a single course setting with a relatively small intervention group, which limits statistical power to detect modest differences in knowledge gain. Second, allocation to the adaptive learning module was voluntary and therefore subject to potential selection bias, although baseline characteristics were comparable between groups. Third, the knowledge assessments consisted of conceptually aligned but non-identical pre- and post-course questionnaires, which precluded the use of repeated-measures statistical models. In addition, the knowledge questionnaire may not have been sufficiently challenging to fully discriminate higher-order cognitive performance, as reflected by the near-ceiling performance observed across several items after course completion. Fourth, time-on-task for the adaptive learning module was not systematically captured and could therefore not be analyzed. Finally, knowledge performance represents a surrogate outcome and does not necessarily translate directly into operative performance or patient outcomes. Another limitation relates to the relatively focused scope of the educational topic. Laparoscopic cholecystectomy represents a well-defined and widely taught procedure in surgical training, and it is therefore plausible that conventional educational approaches may achieve comparable knowledge gains within a short learning period. Future studies should evaluate adaptive learning interventions in randomized designs and assess their longitudinal effects on knowledge retention and clinical performance. Investigating the integration of adaptive learning platforms into surgical training programs over longer periods may further clarify their potential role in supporting guideline-based clinical reasoning and adaptive expertise in surgical trainees. Conclusion In this course-based cohort of surgical trainees, completion of an adaptive pre-course learning module did not result in greater overall knowledge gains compared with standard instruction alone. However, participants exposed to adaptive learning demonstrated higher accuracy in selected guideline-based clinical reasoning items in exploratory analyses. These findings suggest that adaptive learning may support specific aspects of clinical reasoning within surgical education, while overall knowledge acquisition remains strongly influenced by structured in-person training. Declarations Ethics approval and consent to participate All methods were carried out in accordance with relevant guidelines and regulations. This study was conducted in accordance with the Declaration of Helsinki and the Swiss Federal Act on Research involving Human Beings (Human Research Act, HRA; SR 810.30). According to Swiss law and guidance from Swissethics, research involving exclusively irreversibly anonymized data does not fall within the scope of the Human Research Act and therefore does not require approval from a cantonal ethics committee. The competent cantonal ethics committee (Ethikkommission Ostschweiz, EKOS) confirmed that the present study does not fall under the Human Research Act and that no formal ethical approval was required. Participation was voluntary, and all participants provided written informed consent prior to inclusion in the study. Consent for publication Not applicable Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was conducted within the national "Proficiency" research project funded by the Swiss Innovation Agency Innosuisse in 2021 as one of 15 flagship initiatives (https://surgicalproficiency.ch). The funding source is not involved in study design, the collection, analysis and interpretation of data, the writing of the report nor has influenced the decision to submit the article for publication. Authors’ contributions Conception and design of the work: DC, MS, PB, MV, BS, WB, DH, SB Data acquisition & analysis: DC, MS, MV, AV, KB, SB Interpretation of data: DC, PB, AV, DH, SB Drafted the manuscript: DC, PB, SB Substantively revised the manuscript: DC, MS, PB, KB, BS, WB, DH, SB Acknowledgements The authors would like to thank for the support provided by the congress organization of the "Davos Course". References Safety and equity in scaling minimally invasive surgery worldwide in 109 countries using cholecystectomy as a tracer procedure: a prospective cohort study. Lancet Glob Health. 2026;14(2):e199-e212. Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 2003;237(4):460-9. Subramanian S, Michael M, Berglund L, Chu A, Jolbäck P, Blohm M, et al. 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Development of an Adaptive Learning System with Multiple Perspectives based on Students' Learning Styles and Cognitive Styles. Journal of Educational Technology & Society. 2013;16(4):185-200. Güner Gültekin D, Akıncı FN. Overestimating the Self, Outranking the Group: An Experimental Study of Overconfidence Biases in Young Decision-Makers. Behav Sci (Basel). 2025;15(12). Tables Table 1 Baseline participant characteristics by group (Control vs. Intervention) Median (25%, 75%) n (%) Control n=57 Intervention n=22 Statistic Demographics Year of birth 1996(1994, 1997) 1996(1992,1997) U=563, p=0.480 Gender Male 25 (43.9%) 10 (45.5%) x 2 (1)=0.16, p=0.898 Female 32 (56.1%) 12 (54.5%) Handedness? Right-handed 48 (84.2%) 19 (86.4%) x 2 (2)=0.164, p=0.921 Left-handed 4 (7.0%) 1 (4.5%) Ambidextrous 5 (8.8%) 2 (9.1%) Video games experience? Yes 31 (54.4%) 14 (63.6%) x 2 (1)=0.554, p=0.457 No 26 (45.6%) 8 (36.4%) Targeted specialist title? Surgery 55 (96.5%) 21 (95.5%) x 2 (2)=3.365, p=0.186 Urology 2 (3.5%) 0 (0.0%) Undecided 0 (0.0%) 1 (4.5%) Minimal Invasive Surgery Experience In which year of residency / training are you? 1 21 (36.8%) 9 (40.9%) x 2 (4)=2.175, p=0.704 2 20 (35.1%) 10 (45.5%) 3 9 (15.8%) 2 (9.1%) 4 5 (8.8%) 1 (4.5%) 5 2 (3.5%) 0 (0.0%) In which country do you currently work? Switzerland 37 (64.9%) 17 (77.3%) x 2 (1)=1.121, p=0.290 Non-Switzerland 20 (35.1%) 5 (22.7%) How do you currently grade your general overall minimal invasive skills? 1= none, 10= master 3 (2, 4) 3 (1, 4) U=588, p=0.662 What are your three most important reasons why you currently train on a simulator? Improve basic laparoscopic skills 55 (96.5%) 19 (86.4%) x 2 (11)=18.171, p=0.078 Learning in a protected environment (train without patients) 34 (59.6%) 15 (68.2%) Being independent in operating 24 (42.1%) 9 (40.9%) Manage possible complications 18 (31.6%) 9 (40.9%) Career advancement 16 (28.1%) 6 (27.3%) Improving patient care 17 (29.8%) 2 (9.1%) Skill maintenance 15 (26.3%) 2 (9.1%) Mastering advanced laparoscopic skills 10 (17.5%) 2 (9.1%) Mandatory for my board certification 2 (3.5%) 0 (0.0%) My training program mandates this training 2 (3.5%) 0 (0.0%) Other 0 (0.0%) 2 (9.1%) Table 2 Post-course questionnaire response distribution by group. Data are presented as number (percentage).Pearson’s χ² test was used for between-group comparisons. Only items demonstrating statistically significant between-group differences are shown (p<0.05) Question Response Option Control n (%) Intervention n (%) χ² (df) p-value TG18 Grade III classification Pericholecystic fluid 3 (6.4%) 0 (0.0%) χ²(3)=8.183 0.042 Empyema of gallbladder 13 (27.7%) 1 (5.0%) Organ dysfunction 31 (66.0%) 18 (90.0%) Gallbladder wall thickening 0 (0.0%) 1 (5.0%) ICU admission TG18 Grade I 0 (0.0%) 0 (0.0%) χ²(2)=5.365 0.021 Grade II 0 (0.0%) 0 (0.0%) Grade III 29 (61.7%) 18 (90.0%) No mandated ICU admission 18 (38.3%) 2 (10.0%) Difficult LC predictor BMI >25 5 (10.6%) 2 (10.0%) χ²(3)=15.606 0.001 Diabetes 0 (0.0%) 3 (15.0%) Male gender & symptoms >72h 42 (89.4%) 12 (60.0%) Steroid use 0 (0.0%) 3 (15.0%) Table 3 Generalized Linear Model Predicting Knowledge Gain. Δ% represents the change in total percentage knowledge score (post-course minus pre-course). Self-confidence level ≥4 was used as the reference category. Group was coded as intervention versus control. Regression coefficients (B) represent the estimated difference in Δ% associated with each predictor. Model fit statistics: Omnibus χ²(11) = 11.65, p = 0.39; Akaike Information Criterion (AIC) = []; Bayesian Information Criterion (BIC) = []. Statistically significant predictors (p < 0.05) are shown in bold. Predictor B (Δ%) SE 95% CI (Δ%) Wald χ² p-value (Intercept) 12 11.4 –10.0 to 35.0 1 0.28 Self-confidence = 1 –17.8 7.6 –32.6 to –2.9 6 0.019 Self-confidence = 2 –14.7 7.3 –29.1 to –0.3 4 0.046 Self-confidence = 3 –13.1 6.5 –25.9 to –0.4 4 0.043 Self-confidence (≥4, reference) — — — — — Group (Intervention vs Control) 0.8 3.6 –6.3 to +7.9 0.05 0.83 Year of birth –0.6 0.6 –1.7 to +0.5 1 0.29 Appendectomy experience –2.7 2.7 –8.0 to +2.6 1 0.33 Cholecystectomy experience –4.1 2.9 –9.8 to +1.6 2 0.16 Colorectal experience 0.7 4.9 –8.9 to +10.2 0.02 0.89 Bariatric experience — — — — — Hernia experience –2.1 2.7 –7.3 to +3.1 0.61 0.44 Additional Declarations No competing interests reported. Supplementary Files 20260321BMCMedEduSupplementMCquestionnairepostcourse.pdf 20260321BMCMedEduSupplementMCquestionnaireprecourse.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 06 May, 2026 Reviewers invited by journal 27 Mar, 2026 Editor assigned by journal 23 Mar, 2026 Editor invited by journal 23 Mar, 2026 Submission checks completed at journal 21 Mar, 2026 First submitted to journal 21 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9112702","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":614469573,"identity":"2803f206-dd3f-4264-924c-e69ca6d00618","order_by":0,"name":"Dimitrios Chatziisaak","email":"","orcid":"","institution":"Guy's \u0026 St Thomas's NHS Foundation Hospitals NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Dimitrios","middleName":"","lastName":"Chatziisaak","suffix":""},{"id":614469574,"identity":"c13e63c9-368c-4899-8917-41b3a7f021ac","order_by":1,"name":"Moritz Sparn","email":"","orcid":"","institution":"HOCH Health Ostschweiz","correspondingAuthor":false,"prefix":"","firstName":"Moritz","middleName":"","lastName":"Sparn","suffix":""},{"id":614469575,"identity":"2c7e2b30-81dc-49eb-85e9-8b91a129ceeb","order_by":2,"name":"Pascal Burri","email":"","orcid":"","institution":"University Hospital Zurich","correspondingAuthor":false,"prefix":"","firstName":"Pascal","middleName":"","lastName":"Burri","suffix":""},{"id":614469576,"identity":"2bef7430-a227-44be-96a9-69752d9234a2","order_by":3,"name":"Martina Vitz","email":"","orcid":"","institution":"University Hospital of Lausanne","correspondingAuthor":false,"prefix":"","firstName":"Martina","middleName":"","lastName":"Vitz","suffix":""},{"id":614469577,"identity":"52ca6712-2303-4da0-bbfd-2fe022fd2b28","order_by":4,"name":"Angelos Vouris","email":"","orcid":"","institution":"Independent Statistical Consultant (ISC)","correspondingAuthor":false,"prefix":"","firstName":"Angelos","middleName":"","lastName":"Vouris","suffix":""},{"id":614469578,"identity":"637a743c-2ef0-4a9a-a15f-520e0937f353","order_by":5,"name":"Karoline Barthel","email":"","orcid":"","institution":"University Medical Center Mannheim, Heidelberg University","correspondingAuthor":false,"prefix":"","firstName":"Karoline","middleName":"","lastName":"Barthel","suffix":""},{"id":614469579,"identity":"081c154a-4824-4c57-9b5b-7318db109e94","order_by":6,"name":"Bruno Schmied","email":"","orcid":"","institution":"HOCH Health Ostschweiz","correspondingAuthor":false,"prefix":"","firstName":"Bruno","middleName":"","lastName":"Schmied","suffix":""},{"id":614469582,"identity":"3a74ba0e-c5e8-416b-9ee6-7c30d99eb2aa","order_by":7,"name":"Walter Brunner","email":"","orcid":"","institution":"HOCH Health Ostschweiz","correspondingAuthor":false,"prefix":"","firstName":"Walter","middleName":"","lastName":"Brunner","suffix":""},{"id":614469583,"identity":"6b9db140-8372-4d5a-a90a-9b3d8f626be4","order_by":8,"name":"Dieter Hahnloser","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIie3PMUvEMBTA8VeEm+J1TfFLvFIoCkc/S0PhplKHWxwjhXPRvYegX0EXJ4cnAbtUXTs4dHLObQ4FzZ2dlLSrQ/5LwiM/yANwuf5j6udIgYNHu5sPbJjYiScHAnsSyClCvwnSBJnXB3W3fYTCv74i0v3iNKpfno8YJIWNBGomzqsPWPH31/Rps16ePDTF0pBsZSOoWFgyAiHbHNWhVBi3LA4qICGtxN+WvSG3O8L6L4yqScK80uwt7vZkRoicxVyPELNLuLkkLu4NMbtkyJs8OtaYWcn8TXX6kxbips3DTvcJ+hdN2KZniZUM8T8fHn/vcrlcrvG+ASKfYBsdjmEMAAAAAElFTkSuQmCC","orcid":"","institution":"University Hospital of Lausanne","correspondingAuthor":true,"prefix":"","firstName":"Dieter","middleName":"","lastName":"Hahnloser","suffix":""},{"id":614469586,"identity":"b274a739-8663-4599-9709-e4d31c4f449e","order_by":9,"name":"Stephan Bischofberger","email":"","orcid":"","institution":"HOCH Health Ostschweiz","correspondingAuthor":false,"prefix":"","firstName":"Stephan","middleName":"","lastName":"Bischofberger","suffix":""}],"badges":[],"createdAt":"2026-03-13 09:09:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9112702/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9112702/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105904843,"identity":"b7bf4045-ceac-4bdc-b532-577270a895c7","added_by":"auto","created_at":"2026-04-01 10:10:47","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":60033,"visible":true,"origin":"","legend":"\u003cp\u003ePre- and Post-course Correct Answers Scores (%) by Phase and Group.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9112702/v1/0d7d703e626badd85dedc9dc.jpg"},{"id":106723786,"identity":"ee32933f-54ac-48b3-9e9f-223b0d9ce2e2","added_by":"auto","created_at":"2026-04-12 18:14:37","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":70832,"visible":true,"origin":"","legend":"\u003cp\u003eChange in Knowledge Scores (Δ Pre–Post Course) by Phase and Group.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9112702/v1/9d4f642074daf491370b2d1f.jpg"},{"id":106725066,"identity":"092a6592-2767-4c99-9ec9-79b84d2113fd","added_by":"auto","created_at":"2026-04-12 18:31:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1319081,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9112702/v1/ebbc9b1c-5d20-4531-bc65-c34f44fd0f25.pdf"},{"id":105844484,"identity":"e343c62b-c041-4339-8e8b-be989de43853","added_by":"auto","created_at":"2026-03-31 17:33:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":130147,"visible":true,"origin":"","legend":"","description":"","filename":"20260321BMCMedEduSupplementMCquestionnairepostcourse.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9112702/v1/3efc791d53284ba315223acd.pdf"},{"id":105844485,"identity":"1cb61bf4-1fc3-4549-8fc1-e21c9a749baf","added_by":"auto","created_at":"2026-03-31 17:33:06","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":211507,"visible":true,"origin":"","legend":"","description":"","filename":"20260321BMCMedEduSupplementMCquestionnaireprecourse.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9112702/v1/5b435e235f455b1a73a872c5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Adaptive learning for safe cholecystectomy training: effects on knowledge acquisition and guideline-based reasoning in surgical trainees","fulltext":[{"header":"Background","content":"\u003cp\u003eMinimally invasive cholecystectomy is among the most frequently performed surgical procedures worldwide and constitutes a foundational benchmark in surgical training (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Despite its routine nature and the widespread dissemination of safety standards, clinically relevant complications - including bile duct injuries and severe inflammatory sequelae - continue to occur (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These adverse events often reflect not only technical challenges but also cognitive gaps in risk stratification, severity assessment, and intraoperative decision-making (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Accordingly, contemporary surgical education increasingly emphasizes not only psychomotor proficiency but also structured clinical reasoning and guideline-based judgment.\u003c/p\u003e \u003cp\u003eIn parallel with the shift toward competency-based curricula, technology-enhanced learning strategies have expanded substantially, including virtual simulation training, adaptive learning platforms, and artificial intelligence-driven instructional systems (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Virtual simulation training has demonstrated benefits in improving operative performance metrics and technical skills in laparoscopic procedures, including cholecystectomy (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, simulation-based training predominantly targets psychomotor skill acquisition and may insufficiently address higher-order cognitive processes such as guideline integration, dynamic risk assessment, and escalation strategies.\u003c/p\u003e \u003cp\u003eAdaptive learning represents an instructional paradigm designed to tailor educational content to the learner\u0026rsquo;s evolving level of understanding through continuous assessment and individualized feedback (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Such approaches align with conceptual frameworks including the \u0026ldquo;Master Adaptive Learner\u0026rdquo; model, which emphasizes metacognition, self-regulated learning, and adaptive expertise (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). By dynamically reinforcing areas of uncertainty and promoting deeper conceptual integration, adaptive learning may be particularly suited to surgical training, where safe operative practice depends on the integration of evidence-based guidelines with context-sensitive clinical judgment. Nevertheless, empirical evidence evaluating adaptive learning specifically in surgical decision-making contexts remains limited.\u003c/p\u003e \u003cp\u003eTo address this gap, we implemented an adaptive learning module focused on safe laparoscopic cholecystectomy, grounded in the \u0026ldquo;Tokyo Guidelines 2018\u0026rdquo; (TG18) and \u0026ldquo;SAGES Safe Cholecystectomy\u0026rdquo; principles (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The module emphasized severity grading, escalation pathways, and intraoperative risk recognition. We hypothesized that completion of this adaptive pre-course module would enhance knowledge acquisition during a structured surgical training course and, in particular, improve performance on items requiring higher-order guideline-based clinical reasoning compared with standard instruction alone.\u003c/p\u003e \u003cp\u003e The aim of this study was to evaluate the educational impact of this adaptive pre-course intervention on overall knowledge gain and guideline-based clinical reasoning in a cohort of surgical trainees.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis study was designed as a prospective, non-randomized educational intervention conducted during the 42nd Annual Davos GI Course in 2025 (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.davoscourse.ch\u003c/span\u003e\u003cspan address=\"http://www.davoscourse.ch\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The study followed a predefined PICO framework. The population consisted of surgical trainees enrolled in the basic training curriculum of the course. The intervention was completion of an adaptive learning module on safe laparoscopic cholecystectomy prior to course participation. The comparator was participation in the standard course curriculum without exposure to the adaptive module. Knowledge performance before and after course participation served as the outcome measure.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants, Baseline Assessment, and Group Allocation\u003c/h3\u003e\n\u003cp\u003eAll trainees enrolled in the basic training track of the 2025 Davos GI Course were eligible for participation. Study participation required completion of both the pre-course and post-course knowledge assessments. Eligibility criteria for the basic curriculum included less than three years of surgical training and experience of fewer than twenty appendectomies or ten cholecystectomies. No exclusion criteria were applied. No formal a priori sample size calculation was performed, as the study was conducted within the fixed cohort of course participants.\u003c/p\u003e \u003cp\u003ePrior to administration of the pre-course questionnaire and before any educational exposure, participants completed a structured baseline survey capturing demographic and professional characteristics, including year of birth, gender, handedness, year of medical degree, residency year, and country of practice. Participants reported prior experience in minimally invasive appendectomy, cholecystectomy, colorectal, bariatric, and hernia surgery, including entrustable professional activity (EPA) levels where applicable (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Self-assessed minimally invasive competence was recorded using a 10-point Likert scale, and additional items assessed perceived laparoscopic dexterity, tissue handling, operative flow, time\u0026ndash;motion efficiency, and autonomy. Baseline data were collected to allow assessment of group equivalence and to minimize measurement bias.\u003c/p\u003e \u003cp\u003eAn optional adaptive learning module was offered to all participants prior to course commencement. Completion of the module was voluntary and not linked to course certification. Participants received electronic invitations and reminder notifications before the course. Trainees who completed the adaptive module constituted the intervention group, whereas those who did not participate formed the control group. Given the self-selected allocation, baseline equivalence between groups was systematically evaluated across demographic, experiential, and knowledge variables to address potential selection bias.\u003c/p\u003e \u003cp\u003eAll participants attended the structured in-person Basic curriculum of the Davos GI Course, which included didactic lectures, case-based discussions, and simulation-based laparoscopic training sessions (Box trainer exercises). The curriculum was identical for both groups.\u003c/p\u003e\n\u003ch3\u003eAdaptive Learning Intervention\u003c/h3\u003e\n\u003cp\u003eThe adaptive learning module was developed using the Area9 Lyceum platform (Area9 Lyceum, Copenhagen, Denmark). The module focused on safe laparoscopic cholecystectomy and was aligned with the Tokyo Guidelines 2018 (TG18) and SAGES Safe Cholecystectomy principles (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eContent was organized into three domains: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) preoperative assessment and severity grading, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) intraoperative safety strategies including the Critical View of Safety and bailout techniques, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) postoperative complication recognition and management.\u003c/p\u003e \u003cp\u003eThe platform employs an adaptive algorithm that dynamically adjusts item difficulty, sequencing, and feedback based on learner responses. Learners received immediate explanatory feedback and were required to demonstrate mastery of individual concepts before progression. The module was completed asynchronously prior to course participation. Completion data were recorded automatically by the platform.\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcome was the change in total percentage knowledge score (ΔTotal %) from pre-course to post-course assessment.\u003c/p\u003e \u003cp\u003eSecondary outcomes included domain-specific knowledge changes, item-level response differences between groups, and associations between self-reported confidence and knowledge performance.\u003c/p\u003e\n\u003ch3\u003eQuestionnaire Development and Structure\u003c/h3\u003e\n\u003cp\u003eThe pre-course and post-course knowledge assessments were specifically developed for this study. The questionnaires were designed based on the Tokyo Guidelines 2018 (TG18) and SAGES Safe Cholecystectomy principles to evaluate both factual knowledge and guideline-based clinical reasoning across preoperative, intraoperative, and postoperative domains. The pre-course questionnaire consisted of two components: a baseline survey capturing demographic and professional characteristics, prior surgical experience, and self-assessed competence, and a multiple-choice knowledge assessment focusing on laparoscopic cholecystectomy (Supplementary File 1). The post-course questionnaire consisted of a multiple-choice assessment with conceptually aligned items addressing the same domains, allowing evaluation of knowledge acquisition following course participation (Supplementary File 2).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eCategorical variables were summarized as frequencies and percentages and compared between groups using Pearson\u0026rsquo;s χ\u0026sup2; test or Fisher\u0026rsquo;s exact test when appropriate (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Continuous variables were assessed for normality using the Shapiro\u0026ndash;Wilk test and are reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for normally distributed data or median with interquartile range for non-normal distributions (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Because percentage knowledge scores were not normally distributed, nonparametric tests were predominantly applied.\u003c/p\u003e \u003cp\u003eBaseline comparisons between the control and intervention groups were conducted using independent-samples t-tests for normally distributed variables and Mann\u0026ndash;Whitney U tests for non-normal continuous variables (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Item-level response distributions were analyzed separately for pre-course and post-course questionnaires using χ\u0026sup2; tests to identify topic-specific differences between groups. Between-group comparisons of phase-level and total percentage scores at each time point were performed using Mann\u0026ndash;Whitney U tests. Within-group differences across operative phases were assessed using Friedman\u0026rsquo;s test for related samples (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). When significant, post hoc comparisons were interpreted descriptively with Bonferroni-adjusted thresholds (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo isolate the effect of the adaptive learning intervention beyond general course-related improvement, an individual-level Difference-in-Differences (DiD) approach was applied. For each participant, change scores (Δ\u0026thinsp;=\u0026thinsp;post-course percentage\u0026thinsp;\u0026minus;\u0026thinsp;pre-course percentage) were calculated for total and phase-specific knowledge domains. Between-group comparisons of Δ values were performed using Mann\u0026ndash;Whitney U tests or independent-samples t-tests when normality assumptions were met. Mixed-effects modeling was not applied because the pre- and post-course questionnaires contained different but conceptually aligned items. Associations between self-confidence and knowledge performance were assessed using Spearman\u0026rsquo;s rank correlation coefficients, and knowledge scores were compared across categorized confidence levels using Mann\u0026ndash;Whitney U tests.\u003c/p\u003e \u003cp\u003eTo explore predictors of knowledge gain (ΔTotal %), a generalized linear model was constructed including self-confidence level, group assignment, year of birth, and prior minimally invasive procedural experience as independent variables. Regression coefficients, 95% confidence intervals, and p-values were reported, and model fit was evaluated using omnibus χ\u0026sup2; statistics and information criteria.\u003c/p\u003e \u003cp\u003eAll statistical tests were two-tailed, and a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Analyses were performed using IBM SPSS Statistics version 27.0 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e \u003cp\u003eGiven the exploratory nature of item-level analyses, findings should be interpreted cautiously in the context of multiple comparisons.\u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll methods were carried out in accordance with relevant guidelines and regulations. This study was conducted in accordance with the Declaration of Helsinki and the Swiss Federal Act on Research involving Human Beings (Human Research Act, HRA; SR 810.30).\u003c/p\u003e\n\u003cp\u003eAccording to Swiss law and guidance from Swissethics, research involving exclusively irreversibly anonymized data does not fall within the scope of the Human Research Act and therefore does not require approval from a cantonal ethics committee.\u003c/p\u003e\n\u003cp\u003eThe competent cantonal ethics committee (Ethikkommission Ostschweiz, EKOS) confirmed that the present study does not fall under the Human Research Act and that no formal ethical approval was required.\u003c/p\u003e\n\u003cp\u003eParticipation was voluntary, and all participants provided written informed consent prior to inclusion in the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Characteristics and Baseline Equivalence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of \u003cstrong\u003e79 surgical trainees\u003c/strong\u003e participated in the study, including 57 in the control group and 22 in the intervention group. All participants completed both pre-course and post-course assessments. Baseline demographic and professional characteristics did not differ significantly between groups. The median year of birth was 1996 in both cohorts (Control: 1996 [IQR 1994\u0026ndash;1997]; Intervention: 1996 [IQR 1992\u0026ndash;1997]; U = 563, p = 0.480). Gender distribution was comparable (43.9% vs. 45.5% male; \u0026chi;\u0026sup2;(1) = 0.16, p = 0.898), as were handedness, country of practice, and year of medical degree (all p \u0026gt; 0.05). Most participants were early-stage trainees, with 71.9% of the control group and 86.4% of the intervention group in the first or second year of residency (\u0026chi;\u0026sup2;(4) = 2.175, p = 0.704) (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary Outcome: Change in Total Knowledge Score (\u0026Delta;Total %)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIndividual change scores (\u0026Delta; = post \u0026minus; pre) were calculated to assess the primary outcome of total knowledge gain. Median total knowledge improvement was 5% [0\u0026ndash;15%] in the control group and 7.5% [0\u0026ndash;22.5%] in the intervention group (U = 431, p = 0.590). Between-group comparisons of change scores did not demonstrate a statistically significant difference (Figure 2). Phase-specific improvements were comparable between groups (\u0026Delta;Preoperative: U = 447, p = 0.752; \u0026Delta;Intraoperative: U = 424, p = 0.523; \u0026Delta;Postoperative: U = 429, p = 0.560).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSecondary Outcomes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase-Level Knowledge Performance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePre-Course Comparison\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAt baseline, median total percentage scores were identical between groups (Control: 75% [70\u0026ndash;80%]; Intervention: 75% [70\u0026ndash;83%]; U = 456, p = 0.846). Phase-level analysis revealed no differences in preoperative (U = 403.5, p = 0.349) or postoperative domains (U = 397.5, p = 0.232) (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePost-Course Comparison\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAfter course completion, both groups demonstrated improved performance. Median total scores increased to 85% in both cohorts (Control: 85% [75\u0026ndash;90%]; Intervention: 85% [78\u0026ndash;95%]; U = 420.5, p = 0.493). No statistically significant between-group differences were observed in preoperative (U = 435.5, p = 0.630) or intraoperative (U = 367.5, p = 0.115) domains. A difference approaching statistical significance was observed in the postoperative domain (U = 348.5, p = 0.06), with higher median scores in the intervention group (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eWithin-Group Phase Comparisons\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eBefore course participation, both groups demonstrated statistically significant differences across operative phases. In the control group, Friedman\u0026rsquo;s test showed \u0026chi;\u0026sup2;(2) = 11.756 (p = 0.003), with higher scores in the postoperative phase compared with preoperative and intraoperative phases. Similarly, in the intervention group, \u0026chi;\u0026sup2;(2) = 17.360 (p \u0026lt; 0.001), with postoperative knowledge highest. After course completion, phase differences were no longer statistically significant in either group (Control: \u0026chi;\u0026sup2;(2) = 4.068, p = 0.131; Intervention: \u0026chi;\u0026sup2;(2) = 5.463, p = 0.065), indicating a more homogeneous distribution of knowledge across operative domains.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eItem-Level Knowledge Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePre-Course Questionnaire\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNo statistically significant differences were observed between groups across any pre-course questionnaire items (all p \u0026gt; 0.05). Both groups demonstrated strong performance in foundational diagnostic and intraoperative safety concepts, including first-line imaging modality and identification of the Critical View of Safety. Lower accuracy was observed in items requiring severity stratification and complex management decisions, particularly those related to TG18 grading and management of severe sepsis. These patterns were consistent across both groups, indicating shared conceptual difficulty prior to the educational intervention.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePost-Course Questionnaire\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eFollowing course participation, overall accuracy improved in both groups. Most items demonstrated high correct response rates (\u0026gt;85%) across both cohorts. In exploratory item-level analyses, three post-course items showed statistically significant between-group differences: a) Identification of TG18 Grade III (severe) complications (\u0026chi;\u0026sup2;(3) = 8.183, p = 0.042). b) Recognition that TG18 Grade III mandates ICU admission (\u0026chi;\u0026sup2;(2) = 5.365, p = 0.021). c) Identification of predictors of difficult laparoscopic cholecystectomy (\u0026chi;\u0026sup2;(3) = 15.606, p = 0.001). In all three cases, the intervention group demonstrated higher response accuracy compared with controls. All other items, including those related to antibiotic management and intraoperative safety strategies, showed no statistically significant differences, with both groups achieving near-ceiling performance (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-Confidence and Knowledge Performance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo significant correlation was observed between baseline self-confidence and pre-course total knowledge score (Spearman r = 0.015, p = 0.907). This lack of association persisted when analyzed separately by group. When categorized into low and medium confidence levels, no differences were observed in baseline performance. Post-course, participants with medium confidence demonstrated higher total scores (U = 336.5, p = 0.033) and higher preoperative domain scores (U = 324.5, p = 0.020). However, change scores (\u0026Delta;) did not differ significantly between confidence groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMultivariable Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA generalized linear model was constructed to identify predictors of knowledge gain (\u0026Delta;Total %). The overall generalized linear model did not demonstrate statistical significance (Omnibus \u0026chi;\u0026sup2;(11) = 11.65, p = 0.39), indicating limited explanatory power. Group assignment was not associated with knowledge gain (p = 0.83). Self-confidence levels showed a negative association with improvement at lower levels (p values between 0.019 and 0.046), whereas age and prior procedural experience were not significant predictors (all p \u0026gt; 0.15) (Table 3).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis prospective educational intervention study evaluated the impact of an adaptive learning module on knowledge acquisition in safe laparoscopic cholecystectomy within a structured surgical training course. Overall knowledge gains did not differ significantly between trainees who completed the adaptive module and those who participated in the standard curriculum alone. However, exploratory item-level analyses demonstrated higher accuracy in the intervention group for selected questions requiring guideline-based clinical reasoning related to severity grading, ICU indication, and predictors of operative difficulty. These findings suggest that adaptive learning may influence specific aspects of clinical reasoning even when overall knowledge gains remain comparable.\u003c/p\u003e\n\u003cp\u003eThe absence of a significant difference in the primary outcome indicates that short pre-course exposure to adaptive learning does not necessarily produce measurable increases in aggregate knowledge scores in a cohort undergoing intensive in-person instruction. The Davos GI Course provides a highly structured curriculum with lectures, case discussions, and simulation-based training, which likely contributes substantially to knowledge acquisition across participants. In this context, the adaptive module may have functioned primarily as a preparatory tool rather than an independent driver of overall score improvement.\u003c/p\u003e\n\u003cp\u003eNevertheless, the observed differences in selected post-course items are noteworthy. These questions required integration of multiple clinical variables and application of guideline-based reasoning rather than recall of isolated facts. Such tasks correspond to higher levels of cognitive processing within educational frameworks such as Bloom\u0026rsquo;s taxonomy. Adaptive learning systems are designed to identify individual knowledge gaps and reinforce areas of uncertainty through repeated exposure and targeted feedback (7,18,19). It is therefore plausible that the adaptive module supported deeper conceptual integration in areas where baseline understanding was limited.\u003c/p\u003e\n\u003cp\u003eThe pattern of findings may also reflect ceiling effects in several domains of the knowledge assessment. After course completion, both groups achieved high median scores and near-ceiling performance in many items related to fundamental surgical principles. In such situations, improvements in higher-order reasoning may be more difficult to detect through aggregate percentage scores. Similar observations have been reported in educational research evaluating technology-enhanced learning tools, where adaptive systems influence the structure and depth of knowledge rather than simply increasing total scores (20).\u003c/p\u003e\n\u003cp\u003eAn additional observation was the lack of correlation between baseline self-confidence and objective knowledge performance. This finding is consistent with previous literature demonstrating that self-perceived competence does not necessarily reflect actual knowledge or decision-making ability (21). Interestingly, lower self-confidence levels were associated with greater measured improvement in the multivariable model, suggesting that trainees who initially perceived themselves as less confident may have benefited more from structured learning opportunities.\u003c/p\u003e\n\u003cp\u003eFrom an educational perspective, these findings support the potential role of adaptive learning as a complementary preparatory strategy within competency-based surgical curricula. Rather than replacing traditional instruction, adaptive modules may help prime learners for in-person training by reinforcing guideline-based frameworks and highlighting areas of uncertainty prior to course participation.\u003c/p\u003e\n\u003cp\u003eSeveral limitations should be considered when interpreting these results. First, the study was conducted in a single course setting with a relatively small intervention group, which limits statistical power to detect modest differences in knowledge gain. Second, allocation to the adaptive learning module was voluntary and therefore subject to potential selection bias, although baseline characteristics were comparable between groups. Third, the knowledge assessments consisted of conceptually aligned but non-identical pre- and post-course questionnaires, which precluded the use of repeated-measures statistical models. In addition, the knowledge questionnaire may not have been sufficiently challenging to fully discriminate higher-order cognitive performance, as reflected by the near-ceiling performance observed across several items after course completion. Fourth, time-on-task for the adaptive learning module was not systematically captured and could therefore not be analyzed. Finally, knowledge performance represents a surrogate outcome and does not necessarily translate directly into operative performance or patient outcomes.\u003c/p\u003e\n\u003cp\u003eAnother limitation relates to the relatively focused scope of the educational topic. Laparoscopic cholecystectomy represents a well-defined and widely taught procedure in surgical training, and it is therefore plausible that conventional educational approaches may achieve comparable knowledge gains within a short learning period.\u003c/p\u003e\n\u003cp\u003eFuture studies should evaluate adaptive learning interventions in randomized designs and assess their longitudinal effects on knowledge retention and clinical performance. Investigating the integration of adaptive learning platforms into surgical training programs over longer periods may further clarify their potential role in supporting guideline-based clinical reasoning and adaptive expertise in surgical trainees.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this course-based cohort of surgical trainees, completion of an adaptive pre-course learning module did not result in greater overall knowledge gains compared with standard instruction alone. However, participants exposed to adaptive learning demonstrated higher accuracy in selected guideline-based clinical reasoning items in exploratory analyses. These findings suggest that adaptive learning may support specific aspects of clinical reasoning within surgical education, while overall knowledge acquisition remains strongly influenced by structured in-person training.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll methods were carried out in accordance with relevant guidelines and regulations. This study was conducted in accordance with the Declaration of Helsinki and the Swiss Federal Act on Research involving Human Beings (Human Research Act, HRA; SR 810.30).\u003c/p\u003e\n\u003cp\u003eAccording to Swiss law and guidance from Swissethics, research involving exclusively irreversibly anonymized data does not fall within the scope of the Human Research Act and therefore does not require approval from a cantonal ethics committee.\u003c/p\u003e\n\u003cp\u003eThe competent cantonal ethics committee (Ethikkommission Ostschweiz, EKOS) confirmed that the present study does not fall under the Human Research Act and that no formal ethical approval was required.\u003c/p\u003e\n\u003cp\u003eParticipation was voluntary, and all participants provided written informed consent prior to inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted within the national \u0026quot;Proficiency\u0026quot; research project funded by the Swiss Innovation Agency Innosuisse in 2021 as one of 15 flagship initiatives (https://surgicalproficiency.ch). The funding source is not involved in study design, the collection, analysis and interpretation of data, the writing of the report nor has influenced the decision to submit the article for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and design of the work: DC, MS, PB, MV, BS, WB, DH, SB\u003c/p\u003e\n\u003cp\u003eData acquisition \u0026amp; analysis: DC, MS, MV, AV, KB, SB\u003c/p\u003e\n\u003cp\u003eInterpretation of data: DC, PB, AV, DH, SB\u003c/p\u003e\n\u003cp\u003eDrafted the manuscript: DC, PB, SB\u003c/p\u003e\n\u003cp\u003eSubstantively revised the manuscript: DC, MS, PB, KB, BS, WB, DH, SB\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank for the support provided by the congress organization of the \u0026quot;Davos Course\u0026quot;.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSafety and equity in scaling minimally invasive surgery worldwide in 109 countries using cholecystectomy as a tracer procedure: a prospective cohort study. Lancet Glob Health. 2026;14(2):e199-e212.\u003c/li\u003e\n\u003cli\u003eWay LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 2003;237(4):460-9.\u003c/li\u003e\n\u003cli\u003eSubramanian S, Michael M, Berglund L, Chu A, Jolb\u0026auml;ck P, Blohm M, et al. Cognitive frameworks for intraoperative surgical decision-making: A systematic scoping review. Surgery. 2026;190:109935.\u003c/li\u003e\n\u003cli\u003eChatziisaak D, Sparn M, Krstic D, Bauci G, Warschkow R, Brunner W, et al. Be prepared! Impact of structured video-assisted coaching on performance in a simulated bleeding exercise during laparoscopic surgery. Surg Endosc. 2024;38(10):6120-7.\u003c/li\u003e\n\u003cli\u003eSparn MB, Teixeira H, Chatziisaak D, Schmied B, Hahnloser D, Bischofberger S. Virtual reality simulation training in laparoscopic surgery - does it really matter, what simulator to use? Results of a cross-sectional study. BMC Med Educ. 2024;24(1):589.\u003c/li\u003e\n\u003cli\u003eChen X, Liao P, Liu S, Zhu J, Abdullah AS, Xiao Y. Effect of virtual reality training to enhance laparoscopic assistance skills. BMC Med Educ. 2024;24(1):29.\u003c/li\u003e\n\u003cli\u003eEckelt S, Soleymani A, Zheng B, Tavakoli M. Intelligent Tutoring Systems for Adaptive Learning Pathways in Healthcare Training. Stud Health Technol Inform. 2025;330:215-34.\u003c/li\u003e\n\u003cli\u003eWolff M, Hammoud M, Carney M. Developing Master Adaptive Learners: Implementation of a Coaching Program in Graduate Medical Education. West J Emerg Med. 2023;24(1):71-5.\u003c/li\u003e\n\u003cli\u003eYokoe M, Hata J, Takada T, Strasberg SM, Asbun HJ, Wakabayashi G, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25(1):41-54.\u003c/li\u003e\n\u003cli\u003ePucher PH, Brunt LM, Fanelli RD, Asbun HJ, Aggarwal R. SAGES expert Delphi consensus: critical factors for safe surgical practice in laparoscopic cholecystectomy. Surg Endosc. 2015;29(11):3074-85.\u003c/li\u003e\n\u003cli\u003eBramley AL, McKenna L. Entrustable professional activities in entry-level health professional education: A scoping review. Med Educ. 2021;55(9):1011-32.\u003c/li\u003e\n\u003cli\u003eMcHugh ML. The chi-square test of independence. Biochem Med (Zagreb). 2013;23(2):143-9.\u003c/li\u003e\n\u003cli\u003eKim HY. Statistical notes for clinical researchers: Chi-squared test and Fisher\u0026apos;s exact test. Restor Dent Endod. 2017;42(2):152-5.\u003c/li\u003e\n\u003cli\u003eSHAPIRO SS, WILK MB. An analysis of variance test for normality (complete samples)\u0026dagger;. Biometrika. 1965;52(3-4):591-611.\u003c/li\u003e\n\u003cli\u003eMann HB, Whitney DR. On a Test of Whether one of Two Random Variables is Stochastically Larger than the Other. The Annals of Mathematical Statistics. 1947;18(1):50-60.\u003c/li\u003e\n\u003cli\u003eFriedman M. The Use of Ranks to Avoid the Assumption of Normality Implicit in the Analysis of Variance. Journal of the American Statistical Association. 1937;32(200):675-701.\u003c/li\u003e\n\u003cli\u003eEtymologia: Bonferroni correction. Emerg Infect Dis. 2015;21(2):289.\u003c/li\u003e\n\u003cli\u003eLiu H. Personalized learning support system for special education: a real-time feedback mechanism based on deep reinforcement learning. Front Psychol. 2025;16:1658698.\u003c/li\u003e\n\u003cli\u003eTan LY, Hu S, Yeo DJ, Cheong KH. Artificial intelligence-enabled adaptive learning platforms: A review. Computers and Education: Artificial Intelligence. 2025;9:100429.\u003c/li\u003e\n\u003cli\u003eTzu-Chi Y, Gwo-Jen H, Stephen Jen-Hwa Y. Development of an Adaptive Learning System with Multiple Perspectives based on Students\u0026apos; Learning Styles and Cognitive Styles. Journal of Educational Technology \u0026amp; Society. 2013;16(4):185-200.\u003c/li\u003e\n\u003cli\u003eG\u0026uuml;ner G\u0026uuml;ltekin D, Akıncı FN. Overestimating the Self, Outranking the Group: An Experimental Study of Overconfidence Biases in Young Decision-Makers. Behav Sci (Basel). 2025;15(12).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBaseline participant characteristics by group (Control vs. Intervention)\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"126%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eMedian (25%, 75%)\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=57\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=22\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStatistic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" colspan=\"6\" valign=\"top\" style=\"width: 759px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear of birth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e1996(1994, 1997)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e1996(1992,1997)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eU=563, p=0.480\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e25 (43.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e10 (45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ex\u003csup\u003e2\u003c/sup\u003e(1)=0.16, p=0.898\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 161px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e32 (56.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e12 (54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHandedness?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eRight-handed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e48 (84.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e19 (86.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ex\u003csup\u003e2\u003c/sup\u003e(2)=0.164, p=0.921\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 161px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eLeft-handed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e4 (7.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e1 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 161px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eAmbidextrous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e5 (8.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" rowspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVideo games experience?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e31 (54.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e14 (63.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ex\u003csup\u003e2\u003c/sup\u003e(1)=0.554, p=0.457\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e26 (45.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e8 (36.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" rowspan=\"3\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTargeted specialist title?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eSurgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e55 (96.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e21 (95.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ex\u003csup\u003e2\u003c/sup\u003e(2)=3.365, p=0.186\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eUrology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e2 (3.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eUndecided\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e1 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" colspan=\"6\" valign=\"top\" style=\"width: 759px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMinimal Invasive Surgery Experience\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" rowspan=\"4\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIn which year of residency / training are you?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e21 (36.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e9 (40.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ex\u003csup\u003e2\u003c/sup\u003e(4)=2.175, p=0.704\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e20 (35.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e10 (45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e9 (15.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e5 (8.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e1 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 161px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2 (3.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" rowspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIn which country do you currently work?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eSwitzerland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e37 (64.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e17 (77.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ex\u003csup\u003e2\u003c/sup\u003e(1)=1.121, p=0.290\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eNon-Switzerland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e20 (35.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e5 (22.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow do you currently grade your general overall minimal invasive skills? \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e1= none, 10= master\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3 (2, 4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e3 (1, 4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eU=588, p=0.662\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" rowspan=\"3\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat are your three most important reasons why you currently train on a simulator?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eImprove basic laparoscopic skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e55 (96.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e19 (86.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ex\u003csup\u003e2\u003c/sup\u003e(11)=18.171, p=0.078\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eLearning in a protected environment (train without patients)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e34 (59.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e15 (68.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eBeing independent in operating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e24 (42.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e9 (40.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 161px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eManage possible complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e18 (31.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e9 (40.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 161px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eCareer advancement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e16 (28.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e6 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 161px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eImproving patient care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e17 (29.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 161px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eSkill maintenance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e15 (26.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 161px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eMastering advanced laparoscopic skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e10 (17.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 161px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eMandatory for my board certification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2 (3.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 161px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eMy training program mandates this training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2 (3.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 161px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" colspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 139px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 116px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePost-course questionnaire response distribution by group. Data are presented as number (percentage).Pearson\u0026rsquo;s \u0026chi;\u0026sup2; test was used for between-group comparisons. Only items demonstrating statistically significant between-group differences are shown (p\u0026lt;0.05)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\" width=\"747\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponse Option\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026chi;\u0026sup2; (df)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTG18 Grade III classification\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003ePericholecystic fluid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e3 (6.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;(3)=8.183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003eEmpyema of gallbladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e13 (27.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e1 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003eOrgan dysfunction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e31 (66.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e18 (90.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003eGallbladder wall thickening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e1 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eICU admission TG18\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003eGrade I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;(2)=5.365\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003eGrade II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003eGrade III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e29 (61.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e18 (90.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003eNo mandated ICU admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e18 (38.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e2 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifficult LC predictor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003eBMI \u0026gt;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e5 (10.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e2 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;(3)=15.606\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e3 (15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003eMale gender \u0026amp; symptoms \u0026gt;72h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e42 (89.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e12 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 195px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003eSteroid use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e3 (15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGeneralized Linear Model Predicting Knowledge Gain. \u0026Delta;% represents the change in total percentage knowledge score (post-course minus pre-course). Self-confidence level \u0026ge;4 was used as the reference category. Group was coded as intervention versus control. Regression coefficients (B) represent the estimated difference in \u0026Delta;% associated with each predictor. Model fit statistics: Omnibus \u0026chi;\u0026sup2;(11) = 11.65, p = 0.39; Akaike Information Criterion (AIC) = []; Bayesian Information Criterion (BIC) = []. Statistically significant predictors (p \u0026lt; 0.05) are shown in bold.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePredictor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB (\u0026Delta;%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI (\u0026Delta;%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWald \u0026chi;\u0026sup2;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(Intercept)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e11.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026ndash;10.0 to 35.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-confidence = 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026ndash;17.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026ndash;32.6 to \u0026ndash;2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-confidence = 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026ndash;14.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026ndash;29.1 to \u0026ndash;0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.046\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-confidence = 3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026ndash;13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026ndash;25.9 to \u0026ndash;0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-confidence (\u0026ge;4, reference)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup (Intervention vs Control)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026ndash;6.3 to +7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear of birth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026ndash;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026ndash;1.7 to +0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAppendectomy experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026ndash;2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026ndash;8.0 to +2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCholecystectomy experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026ndash;4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026ndash;9.8 to +1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eColorectal experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026ndash;8.9 to +10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBariatric experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHernia experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026ndash;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 14px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026ndash;7.3 to +3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adaptive learning, surgical education, safe cholecystectomy, clinical reasoning, technology-enhanced learning, competency-based education","lastPublishedDoi":"10.21203/rs.3.rs-9112702/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9112702/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e Safe laparoscopic cholecystectomy requires not only technical proficiency but also structured clinical reasoning and guideline-based decision-making. Adaptive learning platforms have emerged as technology-enhanced educational tools designed to personalize instruction and reinforce areas of uncertainty. However, evidence regarding their role in supporting clinical reasoning in surgical education remains limited. This study evaluated the educational impact of an adaptive pre-course learning module on knowledge acquisition in safe laparoscopic cholecystectomy within a structured surgical training course.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a prospective non-randomized educational intervention during the 42nd Annual Davos GI Course in 2025. Surgical trainees enrolled in the basic curriculum were invited to complete an optional adaptive learning module on safe laparoscopic cholecystectomy prior to course participation. Knowledge performance was assessed using pre- and post-course questionnaires. The primary outcome was the change in total percentage knowledge score (ΔTotal %). Secondary outcomes included domain-specific knowledge changes, exploratory item-level response differences, and associations between self-reported confidence and knowledge performance.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSeventy-nine surgical trainees participated, including 57 in the control group and 22 who completed the adaptive learning module. Baseline demographic and professional characteristics were comparable between groups. Median total knowledge improvement was 5% [0\u0026ndash;15%] in the control group and 7.5% [0\u0026ndash;22.5%] in the intervention group, with no statistically significant between-group difference (p\u0026thinsp;=\u0026thinsp;0.590). Domain-specific improvements were similar across groups. In exploratory item-level analyses, three post-course questions requiring guideline-based clinical reasoning demonstrated higher response accuracy in the intervention group. Overall post-course performance showed high correct response rates across most questionnaire items.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAdaptive pre-course learning did not result in greater overall knowledge gains compared with standard instruction alone. However, exploratory findings suggest that adaptive learning may support selected aspects of guideline-based clinical reasoning. Adaptive modules may therefore represent a useful complementary preparatory strategy within structured surgical training programs.\u003c/p\u003e","manuscriptTitle":"Adaptive learning for safe cholecystectomy training: effects on knowledge acquisition and guideline-based reasoning in surgical trainees","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-31 17:33:02","doi":"10.21203/rs.3.rs-9112702/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"108551892224373213587300021678254864936","date":"2026-05-07T00:21:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-27T10:38:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-24T03:35:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-23T12:19:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-21T20:33:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-03-21T20:28:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fee20806-bb22-4852-9127-ef1da86de6d0","owner":[],"postedDate":"March 31st, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"108551892224373213587300021678254864936","date":"2026-05-07T00:21:23+00:00","index":43,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-31T17:33:02+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-31 17:33:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9112702","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9112702","identity":"rs-9112702","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}