Attention Disruptions to the Operating Surgeon During Laparoscopic Cholecystectomy

Introduction: Disruptions to surgical workflow have been correlated with an increase in surgical errors and suboptimal outcomes in patient safety measures. Yet, our ability to quantify such threats to patient safety are woefully inadequate. Data is needed to gauge how the laparoscopic operating room (OR) work environment, where the visual and motor axes are no longer aligned, contributes to such disruptions. We used time motion analysis techniques to measure surgeon attention during laparoscopic cholecystectomy in order to characterize disruptive events imposed by the work environment of the OR. In this investigation, we identify attention diversions as they occur to the operating surgeon. We then quantify the diversions and also establish what occasioned them.

Methods: With approval of the institutional review board, ten laparoscopic cholecystectomy procedures were recorded with both intra- and extra-corporeal cameras (laparoscopic view and room view). The views were synchronized to produce a video that was subsequently analyzed by a single independent observer. Each time the surgeon’s attention was diverted from the operation’s video display, the event was recorded via time-stamp. The reason for looking away (e.g. instrument exchange) was also recorded when discernable and categorized. Disruptions were then reviewed and analyzed by an interdisciplinary team of surgeons and human factors experts.

Results: Attention disruptions fell into one of four categories: instrument exchange, extracorporeal work, equipment troubleshooting, and communication. There were on average 40 breaks in operating surgeon attention per 15 minutes of operating time. The most frequent reasons for these disruptions involved instrument exchange (38% of disruptions) and downward gaze for extracorporeal work (28% of disruptions).

Conclusions: This study reveals that there is a high distraction rate in laparoscopic cholecystectomy in the current OR work environment. Improvements aimed at reducing disruptions—and thus potentially surgical error—should center on better instrument design and realigning the axis between surgeon’s eye and visual display.

Session: Podium Presentation

Program Number: S055

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