Barriers to efficiency in robotic surgery: the resident effect

Abstract

Background Robotic surgery offers advantages over conventional operative approaches, but may also be associated with higher costs and additional risks. Analyzing surgical flow disruptions (FDs), defined as “deviations from the natural progression of an operation,” can help target training techniques and identify opportunities for improvement. Materials and methods Thirty-two Robotic Surgery operations were observed over a six-week period at one 900-bed surgical center. FDs were recorded in detail and classified into one of 11 different categories. Procedure type, robot model, and resident involvement were also recorded. Linear regression analyses were used to evaluate the effects of these parameters on FDs and operative duration. Results Twenty-one prostatectomies, 8 sacrocolpopexies, and 3 nephrectomies were observed. The mean number of FDs was 48.2 (95% CI 38.6–54.8 FDs), and mean operative duration was 163 minutes (95% CI 148–179 minutes). Each FD added 2.4 minutes (p=0.025) to a case’s total operative duration. The number and rate of FDs were significantly affected by resident involvement (p=0.008 and p=0.006, respectively). Resident cases demonstrated mostly Training, Equipment, and Robot Switch FDs, whereas non-resident cases demonstrated mostly Equipment, Instrument Changes, and External Factors FDs. Conclusions Though the FDs encountered in resident training are more frequent, they may not significantly increase operative duration. Other FDs, such as Equipment or External Factors, may be more impactful. Limiting these specific FDs should be the focus of performance improvement efforts.

Systematic review of team performance in minimally invasive abdominal surgery

“…All studies observed complete surgical teams (including surgery, anaesthesia and nursing staff) with the goal of evaluating team performance through surgical workflow analysis and evaluation of disruptive events (9 studies), the relationship between team performance and technical outcomes (3 studies), the relationship between anticipation of surgical steps and team efficiency (1 study) or novel tools to rate team performance (3 studies).…”

“…No study compared robot‐assisted techniques with other approaches. Five studies investigated robot‐assisted techniques and found that this approach to abdominal procedures increases team demands that surgical teams were not always able to address effectively, resulting in increased operating times. The identification and analysis of flow disruptions can provide an evidence base for improving the efficiency and safety of robot‐assisted procedures ( Table S1, supporting information).…”

“…No study compared robot-assisted techniques with other approaches. Five studies investigated robot-assisted techniques and found that this approach to abdominal procedures increases team demands 24 that surgical teams were not always able to address effectively 20 , resulting in increased operating times 27 .…”

“…Construct-based tools included: Oxford Non-Technical Skills (NOTECHS) 19 (4 studies) or Observational Teamwork Assessment for Surgery (OTAS) 33 (3 studies). These tools contained moderate evidence of validity for the 27 3 3 2 1 2 1 1 Zheng et al 30 1 1 1 1 0 4 Allers et al 23 1 1 1 1 0 4 Weigl et al 29 3 2 0 1 0 6 Interference assessment form Healey et al 26 assessed outcome according to Messick's framework, with a range of 8-10 of 15 ( Table 1). Nine studies used an 'incident-based' team performance assessment methodology, classifying non-technical procedural errors or disruptions of surgical flow in order of causation 34 .…”

Diagnosing barriers to safety and efficiency in robotic surgery

“…One way to address the gap between what should happen in the operating room (OR) (‘work as imagined’) and what really happens in the OR (‘work as done’) (Xiao et al 2010) is through direct observation of surgical and other clinical processes (Blandford et al 2015; Guerlain et al 2005; Gurses et al 2012). In previous work, we used direct observation to explore some of the use problems, which we describe as surgical flow disruptions (FDs), associated with the da Vinci robotic surgery system, in relation to surgical context (Catchpole et al 2015) and trainee skill development (Jain et al 2016). In this sub-analysis of those data, we refine the original analysis, looking in detail at the sub-set of the data to provide more interpretive depth that will inform future approaches to the integration of the da Vinci and other robotic systems into surgical environments.…”