title: Does speed matter? The impact of operative time on outcome in laparoscopic surgery.
abstract: BACKGROUND
  Controversy exists concerning the importance of operative time on patient outcomes. It is unclear whether faster is better or haste makes waste or similarly whether slower procedures represent a safe, meticulous approach or inexperienced dawdling. The objective of the present study was to determine the effect of operative time on 30-day outcomes in laparoscopic surgery.
  
  
  METHODS
  Patients who underwent laparoscopic general surgery procedures (colectomy, cholecystectomy, Nissen fundoplication, inguinal hernia, and gastric bypass) from the ACS-NSQIP 2005-2008 participant use file were identified. Exclusion criteria were defined a priori to identify same-day admission, elective procedures. Operative time was divided into deciles and summary statistics were analyzed. Univariate analyses using a Cochran-Armitage test for trend were completed. The effect of operative time on 30-day morbidity was further analyzed for each procedure type using multivariate regression controlling for case complexity and additional patient factors. Patients within the highest deciles were excluded to reduce outlier effect.
  
  
  RESULTS
  A total of 76,748 elective general surgical patients who underwent laparoscopic procedures were analyzed. Univariate analyses of deciles of operative time demonstrated a statistically significant trend (p<0.0001) toward increasing odds of complications with increasing operative time for laparoscopic colectomy (n=10,135), cholecystectomy (n=37,407), Nissen fundoplication (n=4,934), and gastric bypass (n=17,842). The trend was not found to be significant for laparoscopic inguinal hernia repair (n=6,430; p=0.14). Multivariate modeling revealed the effect of operative time to remain significant after controlling for additional patient factors.
  
  
  CONCLUSIONS
  Increasing operative time was associated with increased odds of complications and, therefore, it appears that speed may matter in laparoscopic surgery. These analyses are limited in their inability to adjust for all patient factors, potential confounders, and case complexities. Additional hierarchical multivariate analyses at the surgeon level would be important to examine this relationship further.
authors.affiliation: Department of Surgery, Division of General and Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman St. WACC 460, Boston, MA 02114, USA.
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Jackson
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Wannares
authors.forename: R Todd
authors.initials: RT
authors.lastname: Lancaster
authors.forename: David W
authors.initials: DW
authors.lastname: Rattner
authors.forename: Matthew M
authors.initials: MM
authors.lastname: Hutter
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D011446:Prospective Studies; D012044:Regression Analysis; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome