title: Gaze disruptions experienced by the laparoscopic operating surgeon.
abstract: BACKGROUND
  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 remains inadequate. Data are needed to gauge how the laparoscopic operating room 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 disruptions as they occur in terms of the operating surgeon's gaze. We then quantify such disruptions and also seek to establish what occasioned them.
  
  
  METHODS
  Ten laparoscopic cholecystectomy procedures were recorded with both intra- and extracorporeal cameras. The views were synchronized to produce a video that was subsequently analyzed by a single independent observer. Each time the surgeon's gaze was diverted from the operation's video display, the event was recorded via time-stamp. The reason for looking away (e.g., instrument exchange), when discernable, was also recorded and categorized. Disruptions were then reviewed and analyzed by an interdisciplinary team of surgeons and human factors experts.
  
  
  RESULTS
  Gaze disruptions were classified into one of four causal categories: instrument exchange, extracorporeal work, equipment troubleshooting, and communication. On average, 40 breaks occurred in operating surgeon attention per 15 min of operating time. The most frequent reasons for these disruptions involved instrument exchange (38%) and downward gaze for extracorporeal work (28%).
  
  
  CONCLUSIONS
  This study of laparoscopic cholecystectomy performance reveals a high gaze disruption rate in the current operating room work environment. Improvements aimed at reducing such disruptions-and thus potentially surgical error-should center on better instrument design and realigning the axis between surgeon's eye and visual display.
authors.affiliation: Department of Surgery, University of Maryland School of Medicine, Baltimore, MD 21201-1595, USA.
authors.forename: Erica
authors.initials: E
authors.lastname: Sutton
authors.forename: Yassar
authors.initials: Y
authors.lastname: Youssef
authors.forename: Nora
authors.initials: N
authors.lastname: Meenaghan
authors.forename: Carlos
authors.initials: C
authors.lastname: Godinez
authors.forename: Yan
authors.initials: Y
authors.lastname: Xiao
authors.forename: Tommy
authors.initials: T
authors.lastname: Lee
authors.forename: David
authors.initials: D
authors.lastname: Dexter
authors.forename: Adrian
authors.initials: A
authors.lastname: Park
mesh_terms: D016477:Artifacts; D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D002769:Cholelithiasis / Q000601:surgery*; D004868:Equipment Failure; D006801:Humans; D007091:Image Processing, Computer-Assisted; D019300:Medical Errors / Q000517:prevention & control*; D009873:Operating Rooms; D011446:Prospective Studies; D014741:Video Recording; D000078329:Workforce