title: Safety, efficiency and learning curves in robotic surgery: a human factors analysis.
abstract: Expense, efficiency of use, learning curves, workflow integration and an increased prevalence of serious incidents can all be barriers to adoption. We explored an observational approach and initial diagnostics to enhance total system performance in robotic surgery.
  
  
  
  Eighty-nine robotic surgical cases were observed in multiple operating rooms using two different surgical robots (the S and Si), across several specialties (Urology, Gynecology, and Cardiac Surgery). The main measures were operative duration and rate of flow disruptions-described as 'deviations from the natural progression of an operation thereby potentially compromising safety or efficiency.' Contextual parameters collected were surgeon experience level and training, type of surgery, the model of robot and patient factors. Observations were conducted across four operative phases (operating room pre-incision; robot docking; main surgical intervention; post-console).
  
  
  
  A mean of 9.62 flow disruptions per hour (95 % CI 8.78-10.46) were predominantly caused by coordination, communication, equipment and training problems. Operative duration and flow disruption rate varied with surgeon experience (p = 0.039; p < 0.001, respectively), training cases (p = 0.012; p = 0.007) and surgical type (both p < 0.001). Flow disruption rates in some phases were also sensitive to the robot model and patient characteristics.
  
  
  
  Flow disruption rate is sensitive to system context and generates improvement diagnostics. Complex surgical robotic equipment increases opportunities for technological failures, increases communication requirements for the whole team, and can reduce the ability to maintain vision in the operative field. These data suggest specific opportunities to reduce the training costs and the learning curve.
authors.affiliation: Department of Surgery, Cedars-Sinai Medical Center, 825 N. San Vicente Blvd., Los Angeles, CA, 90069, USA. Ken.Catchpole@cshs.org.
authors.forename: Ken
authors.initials: K
authors.lastname: Catchpole
authors.affiliation: Department of Surgery, Cedars-Sinai Medical Center, 825 N. San Vicente Blvd., Los Angeles, CA, 90069, USA.|David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
authors.forename: Colby
authors.initials: C
authors.lastname: Perkins
authors.affiliation: Biostatistics and Bioinformatics Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: Catherine
authors.initials: C
authors.lastname: Bresee
authors.affiliation: Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: M Jonathon
authors.initials: MJ
authors.lastname: Solnik
authors.affiliation: Medical Student Training in Aging Research (MSTAR) Program, University of California, Los Angeles, CA, USA.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Sherman
authors.affiliation: Medical Student Training in Aging Research (MSTAR) Program, University of California, Los Angeles, CA, USA.
authors.forename: John
authors.initials: J
authors.lastname: Fritch
authors.affiliation: Medical Student Training in Aging Research (MSTAR) Program, University of California, Los Angeles, CA, USA.
authors.forename: Bruno
authors.initials: B
authors.lastname: Gross
authors.affiliation: Medical Student Training in Aging Research (MSTAR) Program, University of California, Los Angeles, CA, USA.
authors.forename: Samantha
authors.initials: S
authors.lastname: Jagannathan
authors.affiliation: Medical Student Training in Aging Research (MSTAR) Program, University of California, Los Angeles, CA, USA.
authors.forename: Niv
authors.initials: N
authors.lastname: Hakami-Majd
authors.affiliation: Department of Surgery, Cedars-Sinai Medical Center, 825 N. San Vicente Blvd., Los Angeles, CA, 90069, USA.
authors.forename: Raymund
authors.initials: R
authors.lastname: Avenido
authors.affiliation: Department of Surgery, Cedars-Sinai Medical Center, 825 N. San Vicente Blvd., Los Angeles, CA, 90069, USA.
authors.forename: Jennifer T
authors.initials: JT
authors.lastname: Anger
mesh_terms: D002983:Clinical Competence; D003142:Communication; D017598:Efficiency, Organizational; D006804:Ergonomics; D005163:Factor Analysis, Statistical; D006801:Humans; D059032:Learning Curve; D015999:Multivariate Analysis; D009873:Operating Rooms / Q000458:organization & administration / Q000706:statistics & numerical data; D061646:Operative Time; D065287:Robotic Surgical Procedures / Q000592:standards* / Q000706:statistics & numerical data; D012371:Robotics / Q000193:education; D012449:Safety; D066231:Surgeons / Q000193:education
keywords: Automation; Error; Human Factors; Robotic surgery; Safety; Teamwork