Surg Endosc DOI 10.1007/s00464-014-3938-3
and Other Interventional Techniques
Surgical team composition differs between laparoscopic and open procedures Bin Zheng • Eric Fung • Bo Fu • Neely M. Panton Lee L. Swanstro¨m
•
Received: 27 March 2014 / Accepted: 1 October 2014 Ó Springer Science+Business Media New York 2014
Abstract Background Performing laparoscopic procedures requires different skill sets and team dynamics compared with open procedures. We evaluated team composition and procedure time between these two surgical approaches using data collected from hospitals in the United State and Canada. Methods A total of 1,260 general surgical cases were reviewed retrospectively, recording the number of operation personnel, procedure complexity, and the procedure time. Results Laparoscopic procedures (n = 930), on average, had a higher procedure difficulty coding which led to a longer procedure time and involved more people in the surgical team than open procedures (n = 330). When we selected cases with matched procedure difficulty coding, laparoscopic procedures (n = 450) still required longer procedure times and involved more operative personnel than open procedures (n = 92).
B. Zheng E. Fung B. Fu Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada B. Zheng (&) Endowed Research Chair in Surgical Simulation, 3-002F Li Ka Shing Centre, 8440 112 St. NW., Edmonton, AB T6G 2E1, Canada e-mail: [email protected] N. M. Panton Department of Surgery, University of British Columbia, Vancouver, BC, Canada L. L. Swanstro¨m Division of GI and MIS, The Oregon Clinic, Portland, OR, USA
Discussion Increased laparoscopic team size and procedure time must be influenced by factors other than case difficulty. The factors may derive from inherent complexity of the surgical setting and team dynamics unique to laparoscopic procedures. Keywords Team composition Team dynamics OR efficiency Retrospective case review Human factors in surgery
Modern surgery requires a well-functioning team [1–3]. Before a patient is moved into the operating room (OR) for a surgical procedure, a number of surgeons, anesthesiologists, nurses, and their assistants are called up to form a surgical team. The welfare of the patient is in the hands of this team rather than the individual surgeon. The efficiency and safety of the operation is dependent on the function of the OR team. Finally, the team requirements and its functionality affect the cost effectiveness of operative interventions—an issue of increasing importance worldwide. Results from our previous studies have revealed that the composition of a surgical team will have an independent impact on the length of procedure time over various surgical procedures [4, 5]. The surgical cases in these two studies include both laparoscopic and open procedures performed by surgeons at two Canadian hospitals and two tertiary care hospitals in Portland, Oregon of the United States. However, the question remains whether teams and team performance are different between laparoscopic and open procedures [4, 5]. In this project, prospectively collected data from all four hospitals are merged, regrouped between laparoscopic and open procedures, and analyzed to examine team performance between these two approaches. In order to examine team performance, we must first define whether the composition of surgical teams is
123
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different in laparoscopic and open procedures. Initial observations might suggest there would be little difference as many similarities exist between performing a laparoscopic procedure and its identical open counterpart. Patients’ medical issues are the same regardless of which approach is chosen. Surgeons and team members face the same surgical challenges and need to follow the identical principles while delivering the surgical treatment. Nursing staff continue to provide the needed assistance and support and anesthesiologists ensure that the patient undergoes the procedure safely and painlessly. Despite these overarching similarities, close inspection of these two approaches reveal differences between laparoscopic and open procedures that may affect team dynamics [6–9]. Unlike an open procedure, a laparoscopic procedure requires a pneumoperitoneum for adequate visualization and operative manipulation [10, 11]. High levels of carbon dioxide inside the abdominal cavity introduce unique physiological effects to the patient during the laparoscopic procedure. As a result, anaesthesiologists are required to increase their vigilance of patient vital signs during the procedure [10, 11]. In a laparoscopic procedure, the visual perspective of the primary surgeon is controlled by an assistant who maneuvers the laparoscope [12, 13]. This necessitates a complex interaction between surgeon and assistant highlighting a need for accurate communication. The high frequency of instrument exchanges during a laparoscopic procedure may add to the task load of nurses who assist in the surgical case [14]. All these elements alter the team dynamic and have potential to influence the team’s performance. Our primary goal in this project is to compare the team composition between laparoscopic and open procedures using the combined data from two Canadian and two USA hospitals. We hypothesize that the surgical team will be larger for the laparoscopic procedures due to its increased inherent complexity. Second, we plan to investigate whether performing a case using laparoscopy required a longer task time than performing an open procedure when cases were adjusted to degree of difficulty.
Methods Team data Surgical team data were previously collected from operations of three general surgeons in two tertiary care hospitals in Portland, Oregon, United States and from two teaching hospitals in Vancouver, British Columbia, Canada [4, 5]. Cases were amalgamated over the course of a single year of practice for each surgeon. Ethical approvals were obtained
123
from local Internal Review Boards (Legacy Health in Portland and University of British Columbia in Vancouver). In each case, we recorded surgical team data including the number of surgeons, anesthesiologists, nurses (scrub and circulating), and others (visitors). We also recorded the patient’s age, gender, American Society of Anesthesiologists (ASA) score, procedure type, and procedure start/end times. Based on the above raw data, we calculated the surgical team size, which included all the attendees (anesthesiologists, surgeons, scrub nurses and circulating nurses, and visitors) assigned to the procedure. Procedure time was defined as time from making the skin incision until wound closure. Index of difficulty of surgery (IDS) The algorithm used to calculate IDS is identical to that applied in previous studies [4, 5]. Briefly, we obtained the Relative Value Unit (RVU) for each procedure. If multiple procedures were performed during a single operation, the RVU of the secondary procedure is halved (multiplied by 0.5) and then added to the RVU of the primary procedure. For a re-operative procedure, the RVU was multiplied by 1.25 reflecting the more complicated steps required when operating for the second time. After establishing the RVU values of each procedure, we normalized RVU to 100 points by dividing the procedure RVU by the maximum RVU within this data set (3,600). The output was denoted as the IDS, i.e., IDS = RVU/3,600 9 100. Team comparison In order to isolate the effect of the laparoscopic or open approach on team size and operative time, it would be ideal to compare the same cases in each category. However, surgeons included in this study had strong preferences of techniques based on the types of procedure. For example, the majority of cholecystectomy and fundoplication cases were performed using laparoscopic techniques while colon resections and hernia repairs were largely performed open. To address this, we compared cases matched for case difficulty. Following our earlier works, we use the Index of IDS to identify cases that pose an equal challenge to the surgical team, regardless whether they are performed laparoscopically or open. The IDS was calculated based on the RVU listed in the Current Procedural Terminology (CPT) [4, 5]. We chose cases with a calculated IDS between 20 and 40 in order to compare team composition and procedure time between laparoscopic and open techniques. A range is necessary for comparison as the open procedures tended toward a lower IDS than laparoscopic procedures, as noted above. Moreover, the IDS values are of a
Surg Endosc
continuous scale and a definition of ‘‘identical IDS’’ would be arbitrary. The analysis with a range allows for more generalization of the results. We chose an IDS of 20–40 as this represented the largest area of overlap between both surgical approaches. By analyzing surgical cases centered around the mean IDS of all reviewed cases we are able to exclude the outliers with very high and low IDS scores. Data analysis To test our first hypothesis, a one-way between subjects ANOVA was used to compare team composition and procedure time between laparoscopic and open procedures using SPSS (Version 11.5, SPSS Inc., Chicago, IL, USA). In order to test the second hypothesis, cases with an IDS between 20 and 40 were selected for comparison. ANOVA was performed to examine whether performing laparoscopic procedures required more team members and longer procedure times than open ones with similar IDS.
Results A total of 1,260 cases were included in the database between the three surgeons: 930 laparoscopic and 330 open cases. Demographics of these cases are listed in Table 1, grouped by the surgical approach. A larger number of complex procedures were performed laparoscopically (IDS = 33.9 ± 14.5) and the mean procedure time in laparoscopic procedures was significantly longer than those open procedures (Laparoscopic 123.7 ± 72.0 vs Open 54.7 ± 52.5 min; p \ 0.001). Team composition: laparoscopic versus open Surgical teams involved in laparoscopic procedures included more members (8.2 ± 1.7 people) than for open
procedures (7.1 ± 1.8 people, p \ 0.001), with relatively more surgeons, nurses and visitors in the OR, though the number of anaesthesiologists stayed constant (Table 2). Team comparison: laparoscopic versus open (with matched IDS) In our dataset, IDS cases between 20 and 40 included different procedures between the laparoscopic and open surgical groups. 450 cases of cholecystectomy (with or without intraoperative cholangiogram), fundoplication, myotomy with Toupet, splenectomy, adrenalectomy (one side or bilateral), and others; a total of 92 cases comprised hernia repair (inguinal, ventral, incision, umbilical, with or without mesh), small bowel resection, and others were in the open category. The mean IDS was equivalent between these two groups (Laparoscopic 25.7 ± 5.0, Open 25.2 ± 5.4; p = 0.421). However, the mean procedure times were significantly longer in the laparoscopic group (95.9 ± 33.2 min) when compared with the open procedures (69.4 ± 46.4 min; p \ 0.001). As seen in the overall comparison, surgical teams involved in laparoscopic procedures were found to be composed of more people than teams for open procedures (8.0 ± 1.6 vs 7.6 ± 1.5 people; p = 0.019). When examining the team composition, we found the larger size in laparoscopic teams was due to more nurses and visitors, and not an increased number of anesthesiologists or surgeons (Table 3).
Discussion Our study shows that laparoscopic teams include more people than teams for open procedures, both overall and when adjusted for degree of difficulty. The number of anesthesiologists did not differ significantly over these two
Table 1 Demographics of reviewed cases Male/all (%)
Age
ASA
IDS
PT (min)
Laparoscopic (n = 930)
46.80
56.0 ± 16.1
2.3 ± 0.8
33.9 ± 14.5
123.7 ± 72.0
Open (n = 330)
51.30
52.8 ± 17.0
2.0 ± 0.8
18.2 ± 12.6
54.7 ± 52.5
.003
.000
.000
.000
p value
ASA American Society of Anesthesiologists Score, IDS index of difficulty of surgery, PT procedure time Table 2 Team comparison between laparoscopic and open procedures Anaesthesiologist
Surgeon
Nurse
Other
Team size
Laparoscopic (n = 930)
1.4 ± 0.5
2.5 ± 0.7
3.9 ± 1.2
0.4 ± 0.7
8.2 ± 1.7
Open (n = 330)
1.4 ± 0.5
2.2 ± 0.8
3.2 ± 1.0
0.2 ± 0.4
7.1 ± 1.8
p value
.161
.000
.000
.000
.000
Other includes industry representatives, radiologists, and visitors
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Surg Endosc Table 3 Team comparison between laparoscopic and open procedures with matched IDS IDS
PT (min)
Anaesthesiologist
Surgeon
Nurse
Other
Team size
Laparoscopic (n = 450)
25.7 ± 5.0
95.9 ± 33.2
1.3 ± 0.5
2.4 ± 0.6
3.7 ± 1.0
0.6 ± 0.7
8.0 ± 1.6
Open (n = 92)
25.2 ± 5.4
69.4 ± 46.4
1.4 ± 0.5
2.3 ± 0.7
3.4 ± 0.9
0.3 ± 0.5
7.6 ± 1.5
p value
.421
.000
.267
.169
.009
.000
.019
Other includes industry representatives, radiologists, and visitors IDS index of difficulty of surgery, PT procedure time
types of procedures although the mean procedure time for laparoscopic procedures was twice as long when compared to open procedures. It was also noted that more surgeons, nurses, and support staff were involved in laparoscopic procedures. The mean IDS of laparoscopic procedures was significantly larger than open procedures (33.9 vs 18.2, Table 1), which may be the root cause for the longer procedure time and the larger surgical team. However, both differences persisted when the cases where adjusted for complexity. Debate exists on whether laparoscopy can achieve equal or even faster operating times compared to open procedures of the same type [15]. Complex procedures required longer time and involved more people [4, 5]. As procedure time increased, more nurses would be assigned to the operation over different work shifts. In laparoscopic procedures, it is common to see industry representatives present in the OR to ensure that the laparoscopic video system and other key equipment (such as harmonic instruments) are working flawlessly [6]. As we noted, a larger number of cholecystectomies are performed laparoscopically. Radiology technicians were frequently invited to the OR to perform intraoperative cholangiogram and contribute to higher team numbers. All these added up to having significantly more team members being involved with laparoscopic procedures compared to the open procedures. Even more interesting to us are the results from testing our second hypothesis. In those cases with equivalent difficulty, we still see a larger team size and longer procedure time for laparoscopic procedures. The results indicate that the team size and procedure time must be influenced by factors other than case difficulty. Such factors may derive from the complexity of the surgical setting and team dynamics of the laparoscopic procedure. By restricting the data collection to only three surgeons in which 542 cases are averaged out, we effectively control between surgeon variability for their overall speed of open and laparoscopic surgery. Moreover, the three surgeons operated collectively at four different sites with constantly changing surgical teams. This study design emphasizes effects on operative time differences due to team performance effects.
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Longer procedure times in laparoscopic procedures may be partially caused by more complicated tools used in the operation. First, laparoscopy is a remote manipulation procedure [7, 16]. Surgical goals are achieved using longshafted and multiple hinged instruments. The outcomes of a tool movement is controlled by the surgeon but also affected by the mechanical properties of the tool [17]. Surgeons need to develop coordination between their hands and the tools: as tool complexity increases, precision of basic manipulation from the hand-tool system is negatively impacted [17]. Additionally, laparoscopic instruments are required to enter the surgical site from a limited number of trocars to the abdominal cavity. Frequent instrument changes in the laparoscopic procedures may also lead to pauses in the workflow that prolong the procedure time [14]. Second, laparoscopy is an image-guided procedure [9]. Building visual coordination in the laparoscopic setting may be another factor that can hinder the surgical performance. Assistant surgeons need to manipulate the laparoscope carefully to provide good visualization for the entire surgical team [12, 13]. Collaboration between team members in a laparoscopic procedure goes beyond hands and tools, but also vision. This is a new challenge of surgeons completing laparoscopic procedures, but is often neglected in surgical skill training curricula. In most cases, visual coordination between surgeons is developed within the OR itself. As such, the primary surgeon often needs to stop the work at hand to correct the visual perspective provided by the assistant [12], especially during the first few cases when a new resident is assigned to the team [18]. Third, surgeons and nurses need to accommodate for the indirect manipulation and develop new types of team collaboration [6]. The level of nurse involvement during a laparoscopic procedure is reported to be less compared to an open procedure [1, 19]. Junior nurses may not perform sufficiently in active team collaboration during laparoscopic procedures, specifically in areas such as anticipation and preparation [6]. Frequent work shifting is common during laparoscopic procedures which may also be a factor to the prolonged procedure time. This factor is amplified if communication between team members is not sufficient during the work shift [6].
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The examination of team composition and member dynamics in the OR offers important insights into potential future optimization of surgical efficiency. Using an objective measure of case difficulty, like IDS, allows identification of other potential factors that affect teams and surgical performance. A limitation from using IDS case controlled comparison is that it does not account for fixed increases in operational time, such as the need to create a pneumoperitoneum. Despite this limitation, it is doubtful it can fully explain the mean differences of 95.6–69.4 min for laparoscopic procedures to open procedures of the same case difficulty. Future studies to investigate this effect would require increased nursing workload and documentation of predefined time points in each procedure. Multiple factors may contribute to a larger team and longer operating times for laparoscopic procedures. Certainly the type of case or the case difficulty increases operation time. Currently most training programs focus on developing surgeon skill with the laparoscopic instruments. However our results may indicate another area of potential improvement. Not only can we improve surgical procedure times by rigorous surgeon training, but we can also target team focused training for laparoscopic procedures. For example, several institutes have begun to place more emphasis on training assistants in their camera maneuvering skills [12, 20, 21]. Inter-professional training has been introduced to improve coordination between surgeons and nurses [22]. All these interventions are aiming in the right direction. Improving team dynamics should help to improve laparoscopic team performance and further reduce procedure time in laparoscopic surgery. Team composition reported in this paper was based on data collected from four hospitals in North America, and reflects management strategy only at tertiary care teaching hospitals. Community hospitals, which encompass a large part of the healthcare system, may develop different strategies in managing OR efficiency. In addition, cases reported here were primary performed by three faculty surgeons at public medical school. Some senior surgeons working in the private setting may have their own operating team members. In these cases, bonding between surgeons and nurses may be quite different from what we observed in the large and busy hospitals. We will need to analyze data from boarder sources before creating a complete description on the surgical team dynamic and its impact on case performance.
Conclusion By analyzing data recorded by the OR staff after each procedure, we show that laparoscopic cases take longer than open cases even when adjusted for case difficulty. We also show that larger operating teams are needed to
perform laparoscopic cases perhaps not only due to their technologic complexity but also because they take a longer time.
Disclosures Bin Zheng, Eric Fung, Lee Swanstro¨m, Neely Panton and Bo Fu have no conflicts of interest or financial ties to disclose.
References 1. Catchpole K, Mishra A, Handa A, McCulloch P (2008) Teamwork and error in the operating room: analysis of skills and roles. Ann Surg 247:699–706 2. Park J, Woodrow SI, Reznick RK, Beales J, MacRae HM (2007) Patient care is a collective responsibility: perceptions of professional responsibility in surgery. Surgery 142:111–118 3. Sexton JB, Makary MA, Tersigni AR, Pryor D, Hendrich A, Thomas EJ, Holzmueller CG, Knight AP, Wu Y, Pronovost PJ (2006) Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel. Anesthesiology 105:877–884 4. Cassera MA, Zheng B, Martinec DV, Dunst CM, Swanstrom LL (2009) Surgical time independently affected by surgical team size. Am J Surg 198:216–222 5. Zheng B, Panton ON, Al-Tayeb TA (2012) Operative length independently affected by surgical team size: data from 2 Canadian hospitals. Can J Surg 55:371–376 6. Zheng B, Taylor MD, Swanstrom LL (2009) An observational study of surgery-related activities between nurses and surgeons during laparoscopic surgery. Am J Surg 197:497–502 7. Berguer R, Forkey DL, Smith WD (1999) Ergonomic problems associated with laparoscopic surgery. Surg Endosc 13:466–468 8. Lee EC, Rafiq A, Merrell R, Ackerman R, Dennerlein JT (2005) Ergonomics and human factors in endoscopic surgery: a comparison of manual vs telerobotic simulation systems. Surg Endosc 19:1064–1070 9. van Det MJ, Meijerink WJ, Hoff C, Totte ER, Pierie JP (2009) Optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites: a review and guidelines. Surg Endosc 23:1279–1285 10. Fried M, Krska Z, Danzig V (2001) Does the laparoscopic approach significantly affect cardiac functions in laparoscopic surgery? Pilot study in non-obese and morbidly obese patients. Obes Surg 11:293–296 11. Tsereteli Z, Terry ML, Bowers SP, Spivak H, Archer SB, Galloway KD, Hunter JG (2002) Prospective randomized clinical trial comparing nitrous oxide and carbon dioxide pneumoperitoneum for laparoscopic surgery. J Am Coll Surg 195:173–179; discussion 179–180 12. Buzink SN, Botden SBI, Heemskerk J, Goossens RM, Ridder H, Jakimowicz J (2009) Camera navigation and tissue manipulation; are these laparoscopic skills related? Surg Endosc 23:750–757 13. Chmarra MK, Kolkman W, Jansen FW, Grimbergen CA, Dankelman J (2007) The influence of experience and camera holding on laparoscopic instrument movements measured with the TrEndo tracking system. Surg Endosc 21:2069–2075 14. Zheng B, Martinec DV, Cassera MA, Swanstrom LL (2008) A quantitative study of disruption in the operating room during laparoscopic antireflux surgery. Surg Endosc 22:2171–2177 15. Kelley JE, Burrus RG, Burns RP, Graham LD, Chandler KE (1993) Safety, efficacy, cost, and morbidity of laparoscopic versus open cholecystectomy: a prospective analysis of 228 consecutive patients. Am Surg 59:23–27
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Surg Endosc ´, 16. Sa´ndor J, Lengyel B, Haidegger T, Saftics G, Papp G, Nagy A We´ber G (2010) Minimally invasive surgical technologies: challenges in education and training. Asian J Endosc Surg 3:101–108 17. Martinec DV, Gatta P, Zheng B, Denk PM, Swanstrom LL (2009) The trade-off between flexibility and maneuverability: task performance with articulating laparoscopic instruments. Surg Endosc 23:2697–2701 18. Kenyon TA, Lenker MP, Bax TW, Swanstrom LL (1997) Cost and benefit of the trained laparoscopic team. A comparative study of a designated nursing team vs a nontrained team. Surg Endosc 11:812–814
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19. McCallin AM (2006) Interdisciplinary researching: exploring the opportunities and risks of working together. Nurs Health Sci 8:88–94 20. Birch DW, Sample C, Gupta R (2007) The impact of a comprehensive course in advanced minimal access surgery on surgeon practice. Can J Surg 50:9–12 21. Aggarwal R, Crochet P, Dias A, Misra A, Ziprin P, Darzi A (2009) Development of a virtual reality training curriculum for laparoscopic cholecystectomy. Br J Surg 96:1086–1093 22. Powell SM, Hill RK (2006) My copilot is a nurse—using crew resource management in the OR. AORN J 83:179–183
and Other Interventional Techniques
Surgical team composition differs between laparoscopic and open procedures Bin Zheng • Eric Fung • Bo Fu • Neely M. Panton Lee L. Swanstro¨m
•
Received: 27 March 2014 / Accepted: 1 October 2014 Ó Springer Science+Business Media New York 2014
Abstract Background Performing laparoscopic procedures requires different skill sets and team dynamics compared with open procedures. We evaluated team composition and procedure time between these two surgical approaches using data collected from hospitals in the United State and Canada. Methods A total of 1,260 general surgical cases were reviewed retrospectively, recording the number of operation personnel, procedure complexity, and the procedure time. Results Laparoscopic procedures (n = 930), on average, had a higher procedure difficulty coding which led to a longer procedure time and involved more people in the surgical team than open procedures (n = 330). When we selected cases with matched procedure difficulty coding, laparoscopic procedures (n = 450) still required longer procedure times and involved more operative personnel than open procedures (n = 92).
B. Zheng E. Fung B. Fu Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada B. Zheng (&) Endowed Research Chair in Surgical Simulation, 3-002F Li Ka Shing Centre, 8440 112 St. NW., Edmonton, AB T6G 2E1, Canada e-mail: [email protected] N. M. Panton Department of Surgery, University of British Columbia, Vancouver, BC, Canada L. L. Swanstro¨m Division of GI and MIS, The Oregon Clinic, Portland, OR, USA
Discussion Increased laparoscopic team size and procedure time must be influenced by factors other than case difficulty. The factors may derive from inherent complexity of the surgical setting and team dynamics unique to laparoscopic procedures. Keywords Team composition Team dynamics OR efficiency Retrospective case review Human factors in surgery
Modern surgery requires a well-functioning team [1–3]. Before a patient is moved into the operating room (OR) for a surgical procedure, a number of surgeons, anesthesiologists, nurses, and their assistants are called up to form a surgical team. The welfare of the patient is in the hands of this team rather than the individual surgeon. The efficiency and safety of the operation is dependent on the function of the OR team. Finally, the team requirements and its functionality affect the cost effectiveness of operative interventions—an issue of increasing importance worldwide. Results from our previous studies have revealed that the composition of a surgical team will have an independent impact on the length of procedure time over various surgical procedures [4, 5]. The surgical cases in these two studies include both laparoscopic and open procedures performed by surgeons at two Canadian hospitals and two tertiary care hospitals in Portland, Oregon of the United States. However, the question remains whether teams and team performance are different between laparoscopic and open procedures [4, 5]. In this project, prospectively collected data from all four hospitals are merged, regrouped between laparoscopic and open procedures, and analyzed to examine team performance between these two approaches. In order to examine team performance, we must first define whether the composition of surgical teams is
123
Surg Endosc
different in laparoscopic and open procedures. Initial observations might suggest there would be little difference as many similarities exist between performing a laparoscopic procedure and its identical open counterpart. Patients’ medical issues are the same regardless of which approach is chosen. Surgeons and team members face the same surgical challenges and need to follow the identical principles while delivering the surgical treatment. Nursing staff continue to provide the needed assistance and support and anesthesiologists ensure that the patient undergoes the procedure safely and painlessly. Despite these overarching similarities, close inspection of these two approaches reveal differences between laparoscopic and open procedures that may affect team dynamics [6–9]. Unlike an open procedure, a laparoscopic procedure requires a pneumoperitoneum for adequate visualization and operative manipulation [10, 11]. High levels of carbon dioxide inside the abdominal cavity introduce unique physiological effects to the patient during the laparoscopic procedure. As a result, anaesthesiologists are required to increase their vigilance of patient vital signs during the procedure [10, 11]. In a laparoscopic procedure, the visual perspective of the primary surgeon is controlled by an assistant who maneuvers the laparoscope [12, 13]. This necessitates a complex interaction between surgeon and assistant highlighting a need for accurate communication. The high frequency of instrument exchanges during a laparoscopic procedure may add to the task load of nurses who assist in the surgical case [14]. All these elements alter the team dynamic and have potential to influence the team’s performance. Our primary goal in this project is to compare the team composition between laparoscopic and open procedures using the combined data from two Canadian and two USA hospitals. We hypothesize that the surgical team will be larger for the laparoscopic procedures due to its increased inherent complexity. Second, we plan to investigate whether performing a case using laparoscopy required a longer task time than performing an open procedure when cases were adjusted to degree of difficulty.
Methods Team data Surgical team data were previously collected from operations of three general surgeons in two tertiary care hospitals in Portland, Oregon, United States and from two teaching hospitals in Vancouver, British Columbia, Canada [4, 5]. Cases were amalgamated over the course of a single year of practice for each surgeon. Ethical approvals were obtained
123
from local Internal Review Boards (Legacy Health in Portland and University of British Columbia in Vancouver). In each case, we recorded surgical team data including the number of surgeons, anesthesiologists, nurses (scrub and circulating), and others (visitors). We also recorded the patient’s age, gender, American Society of Anesthesiologists (ASA) score, procedure type, and procedure start/end times. Based on the above raw data, we calculated the surgical team size, which included all the attendees (anesthesiologists, surgeons, scrub nurses and circulating nurses, and visitors) assigned to the procedure. Procedure time was defined as time from making the skin incision until wound closure. Index of difficulty of surgery (IDS) The algorithm used to calculate IDS is identical to that applied in previous studies [4, 5]. Briefly, we obtained the Relative Value Unit (RVU) for each procedure. If multiple procedures were performed during a single operation, the RVU of the secondary procedure is halved (multiplied by 0.5) and then added to the RVU of the primary procedure. For a re-operative procedure, the RVU was multiplied by 1.25 reflecting the more complicated steps required when operating for the second time. After establishing the RVU values of each procedure, we normalized RVU to 100 points by dividing the procedure RVU by the maximum RVU within this data set (3,600). The output was denoted as the IDS, i.e., IDS = RVU/3,600 9 100. Team comparison In order to isolate the effect of the laparoscopic or open approach on team size and operative time, it would be ideal to compare the same cases in each category. However, surgeons included in this study had strong preferences of techniques based on the types of procedure. For example, the majority of cholecystectomy and fundoplication cases were performed using laparoscopic techniques while colon resections and hernia repairs were largely performed open. To address this, we compared cases matched for case difficulty. Following our earlier works, we use the Index of IDS to identify cases that pose an equal challenge to the surgical team, regardless whether they are performed laparoscopically or open. The IDS was calculated based on the RVU listed in the Current Procedural Terminology (CPT) [4, 5]. We chose cases with a calculated IDS between 20 and 40 in order to compare team composition and procedure time between laparoscopic and open techniques. A range is necessary for comparison as the open procedures tended toward a lower IDS than laparoscopic procedures, as noted above. Moreover, the IDS values are of a
Surg Endosc
continuous scale and a definition of ‘‘identical IDS’’ would be arbitrary. The analysis with a range allows for more generalization of the results. We chose an IDS of 20–40 as this represented the largest area of overlap between both surgical approaches. By analyzing surgical cases centered around the mean IDS of all reviewed cases we are able to exclude the outliers with very high and low IDS scores. Data analysis To test our first hypothesis, a one-way between subjects ANOVA was used to compare team composition and procedure time between laparoscopic and open procedures using SPSS (Version 11.5, SPSS Inc., Chicago, IL, USA). In order to test the second hypothesis, cases with an IDS between 20 and 40 were selected for comparison. ANOVA was performed to examine whether performing laparoscopic procedures required more team members and longer procedure times than open ones with similar IDS.
Results A total of 1,260 cases were included in the database between the three surgeons: 930 laparoscopic and 330 open cases. Demographics of these cases are listed in Table 1, grouped by the surgical approach. A larger number of complex procedures were performed laparoscopically (IDS = 33.9 ± 14.5) and the mean procedure time in laparoscopic procedures was significantly longer than those open procedures (Laparoscopic 123.7 ± 72.0 vs Open 54.7 ± 52.5 min; p \ 0.001). Team composition: laparoscopic versus open Surgical teams involved in laparoscopic procedures included more members (8.2 ± 1.7 people) than for open
procedures (7.1 ± 1.8 people, p \ 0.001), with relatively more surgeons, nurses and visitors in the OR, though the number of anaesthesiologists stayed constant (Table 2). Team comparison: laparoscopic versus open (with matched IDS) In our dataset, IDS cases between 20 and 40 included different procedures between the laparoscopic and open surgical groups. 450 cases of cholecystectomy (with or without intraoperative cholangiogram), fundoplication, myotomy with Toupet, splenectomy, adrenalectomy (one side or bilateral), and others; a total of 92 cases comprised hernia repair (inguinal, ventral, incision, umbilical, with or without mesh), small bowel resection, and others were in the open category. The mean IDS was equivalent between these two groups (Laparoscopic 25.7 ± 5.0, Open 25.2 ± 5.4; p = 0.421). However, the mean procedure times were significantly longer in the laparoscopic group (95.9 ± 33.2 min) when compared with the open procedures (69.4 ± 46.4 min; p \ 0.001). As seen in the overall comparison, surgical teams involved in laparoscopic procedures were found to be composed of more people than teams for open procedures (8.0 ± 1.6 vs 7.6 ± 1.5 people; p = 0.019). When examining the team composition, we found the larger size in laparoscopic teams was due to more nurses and visitors, and not an increased number of anesthesiologists or surgeons (Table 3).
Discussion Our study shows that laparoscopic teams include more people than teams for open procedures, both overall and when adjusted for degree of difficulty. The number of anesthesiologists did not differ significantly over these two
Table 1 Demographics of reviewed cases Male/all (%)
Age
ASA
IDS
PT (min)
Laparoscopic (n = 930)
46.80
56.0 ± 16.1
2.3 ± 0.8
33.9 ± 14.5
123.7 ± 72.0
Open (n = 330)
51.30
52.8 ± 17.0
2.0 ± 0.8
18.2 ± 12.6
54.7 ± 52.5
.003
.000
.000
.000
p value
ASA American Society of Anesthesiologists Score, IDS index of difficulty of surgery, PT procedure time Table 2 Team comparison between laparoscopic and open procedures Anaesthesiologist
Surgeon
Nurse
Other
Team size
Laparoscopic (n = 930)
1.4 ± 0.5
2.5 ± 0.7
3.9 ± 1.2
0.4 ± 0.7
8.2 ± 1.7
Open (n = 330)
1.4 ± 0.5
2.2 ± 0.8
3.2 ± 1.0
0.2 ± 0.4
7.1 ± 1.8
p value
.161
.000
.000
.000
.000
Other includes industry representatives, radiologists, and visitors
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Surg Endosc Table 3 Team comparison between laparoscopic and open procedures with matched IDS IDS
PT (min)
Anaesthesiologist
Surgeon
Nurse
Other
Team size
Laparoscopic (n = 450)
25.7 ± 5.0
95.9 ± 33.2
1.3 ± 0.5
2.4 ± 0.6
3.7 ± 1.0
0.6 ± 0.7
8.0 ± 1.6
Open (n = 92)
25.2 ± 5.4
69.4 ± 46.4
1.4 ± 0.5
2.3 ± 0.7
3.4 ± 0.9
0.3 ± 0.5
7.6 ± 1.5
p value
.421
.000
.267
.169
.009
.000
.019
Other includes industry representatives, radiologists, and visitors IDS index of difficulty of surgery, PT procedure time
types of procedures although the mean procedure time for laparoscopic procedures was twice as long when compared to open procedures. It was also noted that more surgeons, nurses, and support staff were involved in laparoscopic procedures. The mean IDS of laparoscopic procedures was significantly larger than open procedures (33.9 vs 18.2, Table 1), which may be the root cause for the longer procedure time and the larger surgical team. However, both differences persisted when the cases where adjusted for complexity. Debate exists on whether laparoscopy can achieve equal or even faster operating times compared to open procedures of the same type [15]. Complex procedures required longer time and involved more people [4, 5]. As procedure time increased, more nurses would be assigned to the operation over different work shifts. In laparoscopic procedures, it is common to see industry representatives present in the OR to ensure that the laparoscopic video system and other key equipment (such as harmonic instruments) are working flawlessly [6]. As we noted, a larger number of cholecystectomies are performed laparoscopically. Radiology technicians were frequently invited to the OR to perform intraoperative cholangiogram and contribute to higher team numbers. All these added up to having significantly more team members being involved with laparoscopic procedures compared to the open procedures. Even more interesting to us are the results from testing our second hypothesis. In those cases with equivalent difficulty, we still see a larger team size and longer procedure time for laparoscopic procedures. The results indicate that the team size and procedure time must be influenced by factors other than case difficulty. Such factors may derive from the complexity of the surgical setting and team dynamics of the laparoscopic procedure. By restricting the data collection to only three surgeons in which 542 cases are averaged out, we effectively control between surgeon variability for their overall speed of open and laparoscopic surgery. Moreover, the three surgeons operated collectively at four different sites with constantly changing surgical teams. This study design emphasizes effects on operative time differences due to team performance effects.
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Longer procedure times in laparoscopic procedures may be partially caused by more complicated tools used in the operation. First, laparoscopy is a remote manipulation procedure [7, 16]. Surgical goals are achieved using longshafted and multiple hinged instruments. The outcomes of a tool movement is controlled by the surgeon but also affected by the mechanical properties of the tool [17]. Surgeons need to develop coordination between their hands and the tools: as tool complexity increases, precision of basic manipulation from the hand-tool system is negatively impacted [17]. Additionally, laparoscopic instruments are required to enter the surgical site from a limited number of trocars to the abdominal cavity. Frequent instrument changes in the laparoscopic procedures may also lead to pauses in the workflow that prolong the procedure time [14]. Second, laparoscopy is an image-guided procedure [9]. Building visual coordination in the laparoscopic setting may be another factor that can hinder the surgical performance. Assistant surgeons need to manipulate the laparoscope carefully to provide good visualization for the entire surgical team [12, 13]. Collaboration between team members in a laparoscopic procedure goes beyond hands and tools, but also vision. This is a new challenge of surgeons completing laparoscopic procedures, but is often neglected in surgical skill training curricula. In most cases, visual coordination between surgeons is developed within the OR itself. As such, the primary surgeon often needs to stop the work at hand to correct the visual perspective provided by the assistant [12], especially during the first few cases when a new resident is assigned to the team [18]. Third, surgeons and nurses need to accommodate for the indirect manipulation and develop new types of team collaboration [6]. The level of nurse involvement during a laparoscopic procedure is reported to be less compared to an open procedure [1, 19]. Junior nurses may not perform sufficiently in active team collaboration during laparoscopic procedures, specifically in areas such as anticipation and preparation [6]. Frequent work shifting is common during laparoscopic procedures which may also be a factor to the prolonged procedure time. This factor is amplified if communication between team members is not sufficient during the work shift [6].
Surg Endosc
The examination of team composition and member dynamics in the OR offers important insights into potential future optimization of surgical efficiency. Using an objective measure of case difficulty, like IDS, allows identification of other potential factors that affect teams and surgical performance. A limitation from using IDS case controlled comparison is that it does not account for fixed increases in operational time, such as the need to create a pneumoperitoneum. Despite this limitation, it is doubtful it can fully explain the mean differences of 95.6–69.4 min for laparoscopic procedures to open procedures of the same case difficulty. Future studies to investigate this effect would require increased nursing workload and documentation of predefined time points in each procedure. Multiple factors may contribute to a larger team and longer operating times for laparoscopic procedures. Certainly the type of case or the case difficulty increases operation time. Currently most training programs focus on developing surgeon skill with the laparoscopic instruments. However our results may indicate another area of potential improvement. Not only can we improve surgical procedure times by rigorous surgeon training, but we can also target team focused training for laparoscopic procedures. For example, several institutes have begun to place more emphasis on training assistants in their camera maneuvering skills [12, 20, 21]. Inter-professional training has been introduced to improve coordination between surgeons and nurses [22]. All these interventions are aiming in the right direction. Improving team dynamics should help to improve laparoscopic team performance and further reduce procedure time in laparoscopic surgery. Team composition reported in this paper was based on data collected from four hospitals in North America, and reflects management strategy only at tertiary care teaching hospitals. Community hospitals, which encompass a large part of the healthcare system, may develop different strategies in managing OR efficiency. In addition, cases reported here were primary performed by three faculty surgeons at public medical school. Some senior surgeons working in the private setting may have their own operating team members. In these cases, bonding between surgeons and nurses may be quite different from what we observed in the large and busy hospitals. We will need to analyze data from boarder sources before creating a complete description on the surgical team dynamic and its impact on case performance.
Conclusion By analyzing data recorded by the OR staff after each procedure, we show that laparoscopic cases take longer than open cases even when adjusted for case difficulty. We also show that larger operating teams are needed to
perform laparoscopic cases perhaps not only due to their technologic complexity but also because they take a longer time.
Disclosures Bin Zheng, Eric Fung, Lee Swanstro¨m, Neely Panton and Bo Fu have no conflicts of interest or financial ties to disclose.
References 1. Catchpole K, Mishra A, Handa A, McCulloch P (2008) Teamwork and error in the operating room: analysis of skills and roles. Ann Surg 247:699–706 2. Park J, Woodrow SI, Reznick RK, Beales J, MacRae HM (2007) Patient care is a collective responsibility: perceptions of professional responsibility in surgery. Surgery 142:111–118 3. Sexton JB, Makary MA, Tersigni AR, Pryor D, Hendrich A, Thomas EJ, Holzmueller CG, Knight AP, Wu Y, Pronovost PJ (2006) Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel. Anesthesiology 105:877–884 4. Cassera MA, Zheng B, Martinec DV, Dunst CM, Swanstrom LL (2009) Surgical time independently affected by surgical team size. Am J Surg 198:216–222 5. Zheng B, Panton ON, Al-Tayeb TA (2012) Operative length independently affected by surgical team size: data from 2 Canadian hospitals. Can J Surg 55:371–376 6. Zheng B, Taylor MD, Swanstrom LL (2009) An observational study of surgery-related activities between nurses and surgeons during laparoscopic surgery. Am J Surg 197:497–502 7. Berguer R, Forkey DL, Smith WD (1999) Ergonomic problems associated with laparoscopic surgery. Surg Endosc 13:466–468 8. Lee EC, Rafiq A, Merrell R, Ackerman R, Dennerlein JT (2005) Ergonomics and human factors in endoscopic surgery: a comparison of manual vs telerobotic simulation systems. Surg Endosc 19:1064–1070 9. van Det MJ, Meijerink WJ, Hoff C, Totte ER, Pierie JP (2009) Optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites: a review and guidelines. Surg Endosc 23:1279–1285 10. Fried M, Krska Z, Danzig V (2001) Does the laparoscopic approach significantly affect cardiac functions in laparoscopic surgery? Pilot study in non-obese and morbidly obese patients. Obes Surg 11:293–296 11. Tsereteli Z, Terry ML, Bowers SP, Spivak H, Archer SB, Galloway KD, Hunter JG (2002) Prospective randomized clinical trial comparing nitrous oxide and carbon dioxide pneumoperitoneum for laparoscopic surgery. J Am Coll Surg 195:173–179; discussion 179–180 12. Buzink SN, Botden SBI, Heemskerk J, Goossens RM, Ridder H, Jakimowicz J (2009) Camera navigation and tissue manipulation; are these laparoscopic skills related? Surg Endosc 23:750–757 13. Chmarra MK, Kolkman W, Jansen FW, Grimbergen CA, Dankelman J (2007) The influence of experience and camera holding on laparoscopic instrument movements measured with the TrEndo tracking system. Surg Endosc 21:2069–2075 14. Zheng B, Martinec DV, Cassera MA, Swanstrom LL (2008) A quantitative study of disruption in the operating room during laparoscopic antireflux surgery. Surg Endosc 22:2171–2177 15. Kelley JE, Burrus RG, Burns RP, Graham LD, Chandler KE (1993) Safety, efficacy, cost, and morbidity of laparoscopic versus open cholecystectomy: a prospective analysis of 228 consecutive patients. Am Surg 59:23–27
123
Surg Endosc ´, 16. Sa´ndor J, Lengyel B, Haidegger T, Saftics G, Papp G, Nagy A We´ber G (2010) Minimally invasive surgical technologies: challenges in education and training. Asian J Endosc Surg 3:101–108 17. Martinec DV, Gatta P, Zheng B, Denk PM, Swanstrom LL (2009) The trade-off between flexibility and maneuverability: task performance with articulating laparoscopic instruments. Surg Endosc 23:2697–2701 18. Kenyon TA, Lenker MP, Bax TW, Swanstrom LL (1997) Cost and benefit of the trained laparoscopic team. A comparative study of a designated nursing team vs a nontrained team. Surg Endosc 11:812–814
123
19. McCallin AM (2006) Interdisciplinary researching: exploring the opportunities and risks of working together. Nurs Health Sci 8:88–94 20. Birch DW, Sample C, Gupta R (2007) The impact of a comprehensive course in advanced minimal access surgery on surgeon practice. Can J Surg 50:9–12 21. Aggarwal R, Crochet P, Dias A, Misra A, Ziprin P, Darzi A (2009) Development of a virtual reality training curriculum for laparoscopic cholecystectomy. Br J Surg 96:1086–1093 22. Powell SM, Hill RK (2006) My copilot is a nurse—using crew resource management in the OR. AORN J 83:179–183
