Abstract

Introduction: Operative interpretation is central to the educational value of theatre placements, yet students often struggle to apply preclinical anatomy to the operative setting. Evidence increasingly supports teaching anatomy in a direct operative surgical context, rather than as isolated foundational knowledge. Such integration may better prepare learners for operative interpretation, in which anatomical knowledge must be applied to dynamic intraoperative views. This study examined whether the modality used for contextual vertical integration (CVI) of anatomy influences cognitive load and performance during an operative interpretation task.

Methods: In a multi-centre, three-arm, cluster-randomised superiority trial across three Indian medical colleges, tutorial groups of MBBS students received a 60-min CVI session on pelvic anatomy for total laparoscopic hysterectomy with bilateral salpingo-oophorectomy via cadaveric prosection (CP), interactive three-dimensional digital anatomy (I3DD), or slide-based instruction (SB). One week later, students viewed an operative video, completed a 14-item surgical anatomy assessment, and rated intrinsic, extraneous, and germane cognitive load using an adapted Krieglstein questionnaire. Linear mixed models accounted for clustering at the tutorial-group level, with institution included as a fixed effect. Secondary outcomes included perceptions of cognitive load for the anatomy CVI session and a Cost-Consequence Analysis.

Results: Of 400 students taught, 394 consented, and 383 completed the primary outcome assessment. Significant intervention effects were found for intrinsic, extraneous, and germane cognitive load during operative interpretation, and for surgical anatomy performance (all p < 0.001). Compared with CP and I3DD, SB was associated with higher intrinsic load, higher extraneous load, lower germane processing, and poorer surgical anatomy performance. Effect sizes for SB versus CP/I3DD were large for extraneous and germane load and moderate-to-large for surgical anatomy performance. No significant differences were detected between CP and I3DD for operative-interpretation cognitive load or performance. Per-student costs were ₹621 for CP, ₹361 for I3DD, and ₹143 for SB.

Discussion: Three-dimensional, spatially congruent modalities appear to support transfer to operative interpretation more effectively than two-dimensional instruction, likely by reducing representational mismatch and avoidable processing demands. Cadaveric prosection and interactive 3D digital anatomy produced similarly favourable downstream cognitive load and performance outcomes, suggesting that the educational benefit may lie chiefly in preserving representational dimensionality during CVI.