title: Detecting performance variance in complex surgical procedures: analysis of a step-wise technique for laparoscopic right hepatectomy.
abstract: BACKGROUND
  Laparoscopic right hepatectomy (LRH) is a technically challenging operation. Our aim is to evaluate a standardized technique of LRH and determine variances in performance.
  
  
  METHODS
  The procedure was deconstructed into 7 major step-wise components. All LRH followed the same surgical sequence, and used the same devices and operating room set-up. Thirty randomly selected video recordings of the procedure underwent intraoperative time analysis. The variances measured by standard deviation of each step were calculated (mean in minutes ± standard deviation).
  
  
  RESULTS
  Mean total operative time was 114 ± 25 min. The steps with the least variance were inferior vena cava dissection (8 ± 3) and right hepatic vein ligation (9 ± 5). The longest and also the step with the greatest variance was parenchymal transection (35 ± 12).
  
  
  CONCLUSIONS
  LRH can be performed consistently using a standardized step-wise technique. Parenchymal transection had most variation, and this could be explained by intrinsic liver factors. Surgical performance improvement should begin with deconstructing the operation into definable steps to identify areas for change.
authors: Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA.
authors: Juan P
authors: JP
authors: Toro
authors: Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA.
authors: Ankit D
authors: AD
authors: Patel
authors: Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA.
authors: Nathaniel W
authors: NW
authors: Lytle
authors: Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA.
authors: John F
authors: JF
authors: Sweeney
authors: Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA.
authors: Rachel L
authors: RL
authors: Medbery
authors: Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA.
authors: Steven
authors: S
authors: Scott Davis
authors: Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA.
authors: Edward
authors: E
authors: Lin
authors: Department of Surgery, Emory Endosurgery and HPB Surgery Units, Emory University, Atlanta, GA, USA. Electronic address: jsarmie@emory.edu.
authors: Juan M
authors: JM
authors: Sarmiento
mesh_terms: D006498:Hepatectomy / Q000592:standards*; D006801:Humans; D010535:Laparoscopy / Q000592:standards*; D061646:Operative Time; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011446:Prospective Studies
keywords: Laparoscopic right hepatectomy; Manufacturing productivity tools; Step-wise technique; Variance