Deconstructing Operative Flow – a Focus on Anticipatory Movements

Introduction: Efficient instrument movement is a vital part of a well-coordinated operating environment, and is a reflection of optimized ergonomic and human factor issues. In order to make assessments of these movements, objective, reproducible metrics are needed. In this study, instrument flow analysis is utilized to characterize anticipatory movements of the operative team.
Methods: Five laparoscopic Nissen fundoplication operations performed by an expert surgeon and a dedicated minimally invasive surgery team were analyzed using synchronized video feeds from two exterior cameras and the laparoscope. Instrument location was tracked for the duration of the procedure to one of 12 different locations: the 5 access ports; the 4 members of the operating team; on the top or bottom half the patient; and the instrument stand. The flow of instruments from the scrub technician to the primary surgeon was analyzed for patterns suggestive of anticipatory movements.
Results: For the five cases, there were a total of 44 instrument exchanges between the scrub technician and the primary surgeon. The average duration the technician held an instrument before handing it to the surgeon ranged from 0.68s to 42.17s. The needle driver was held for an average of 42.17s prior to handing to the surgeon, and the scissors 20.51s – reflective of the technician anticipating the need for these instruments, and holding or preparing them for the surgeon. With a short average hold time of 0.68s, the curved dissector used for a specific element of the case, was not well anticipated. Other exchanges were with the liver retractor (3.11s), and standard dissector (8.26s). Regardless of anticipation, the surgeon did not have to wait long for any instruments, with an average wait time of 1.30s, and no significant correlation with anticipatory hold time by the technician.
Conclusion: Our approach to analyzing operative flow provides an objective approach to breaking down an operation and identifying effective and ineffective patterns of movement. In the environment of an expert surgeon and dedicated team, instrument transfers are highly efficient, and even unanticipated instrument movements are compensated for with little lost time. Further study will examine the inefficiencies often seen with non-dedicated teams and help delineate the factors that contribute to efficient surgical flow. Ongoing deconstruction of operative flow and establishment of metrics will continue to be central to these analyses.

Session: Podium Presentation

Program Number: S052

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