eoSurgical are now part of the Limbs & Things family

NOTSS meets eoSurgical


Non-Technical Skills for Surgeons (NOTSS) are fundamental to safe patient care. Implementation of NOTSS- training has been shown to lead to safer and more effective surgical care*. All three directors at eoSurgical are Fellows of Royal College of Surgeons or Edinburgh (RCSEd) and work in busy NHS organisations. The RCSEd continues to take the lead when it comes to NOTSS – building a taxonomy and training system and raising awareness. Four categories of surgeons' non-technical skills have been defined: situation awareness, decision making, communication & teamwork, and leadership. The RCSEd has developed two online learning objectives:


NOTSS in a Box (for senior trainees and consultants)

NOTSS for Trainees (for early stage trainees).


What has not existed, until now, is an application of NOTSS to technique-centric simulators. A critical aspect of a surgeon’s non-technical skillset is to ensure that their performance remains unaffected by pressure and distraction. Stressful stimuli originating from the operating environment severely impact a surgeon’s workflow and technical proficiency. We have therefore developed NOTSS-inspired overlay modules that aim to recapitulate visual and auditory pressure during surgery.

Visual distraction, in the form of fade-to-red obscuration of the surgical field, can now be programmed. The rate of ‘red-out’ of the surgical field can be personalised to increase/decrease pressure. Auditory stress is generated by turning on a soundtrack (consisting of varying rate heart rate monitor, background noise from operating machinery, work-unrelated conversations, and a ringing telephone).


We have shown (manuscript in preparation) that these overlays have an impact upon surgeon performance. Trainee performance worsened in conditions of distraction (auditory or visual) whereas seasoned consultants maintained their performance better. We hypothesise that simulated training in the context of distraction and pressure will help trainees to maintain their performance levels better in real world situations.

These modules are now available as part of SurgTrac, our comprehensive curriculum of laparoscopic tasks. If you would like to know more, or have more NOTSS-related ideas, please get in touch.

Mark Hughes

Consultant Neurosurgeon and Honorary Senior Lecturer, Edinburgh

Director, eoSurgical

Email: mark.hughes@eosurgical.com

Twitter: @eosurgical


* Crossley J, Marriott J, Purdie H & Beard JD (2011). Prospective observational study to evaluate NOTSS (Non-Technical Skills for Surgeons) for assessing trainees’ non-technical performance in the operating theatre. British Journal of Surgery. 98, 1010-1020.