Barriers to efficiency in robotic surgery: the resident effect.
Robotic surgery offers advantages over conventional operative approaches but may also be associated with higher costs and additional risks. Analyzing surgical flow disruptions (FDs), defined as "deviations from the natural progression of an operation," can help target training techniques and identify opportunities for improvement.



Thirty-two robotic surgery operations were observed over a 6-wk period at one 900-bed surgical center. FDs were recorded in detail and classified into one of 11 different categories. Procedure type, robot model, and resident involvement were also recorded. Linear regression analyses were used to evaluate the effects of these parameters on FDs and operative duration.



Twenty-one prostatectomies, eight sacrocolpopexies, and three nephrectomies were observed. The mean number of FDs was 48.2 (95% confidence interval [CI] 38.6-54.8 FDs), and mean operative duration was 163 min (95% CI 148-179 min). Each FD added 2.4 min (P = 0.025) to a case's total operative duration. The number and rate of FDs were significantly affected by resident involvement (P = 0.008 and P = 0.006, respectively). Resident cases demonstrated mostly training, equipment, and robot switch FDs, whereas nonresident cases demonstrated mostly equipment, instrument changes, and external factor FDs.



Although the FDs encountered in resident training are more frequent, they may not significantly increase operative duration. Other FDs, such as equipment or external factors, may be more impactful. Limiting these specific FDs should be the focus of performance improvement efforts.
Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California.
Monica
M
Jain
University of Michigan Medical School, Ann Arbor, Michigan.
Brian T
BT
Fry
Eberly College of Science, Pennsylvania State University, Pennsylvania.
Luke W
LW
Hess
Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California.
Jennifer T
JT
Anger
Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California.
Bruce L
BL
Gewertz
Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California; Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina. Electronic address: catchpol@musc.edu.
Ken
K
Catchpole
D017598:Efficiency, Organizational; D006801:Humans; D007396:Internship and Residency; D016014:Linear Models; D009392:Nephrectomy / Q000193:education / Q000379:methods* / Q000706:statistics & numerical data; D061646:Operative Time; D010348:Patient Care Team / Q000458:organization & administration*; D011446:Prospective Studies; D011468:Prostatectomy / Q000193:education / Q000379:methods* / Q000706:statistics & numerical data; D065287:Robotic Surgical Procedures / Q000193:education / Q000706:statistics & numerical data; D066231:Surgeons / Q000193:education / Q000458:organization & administration; D014481:United States
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