Ahmed Aly Hussein Aly

OBJECTIVES: To design a methodology to predict operative times for robot-assisted radical cystectomy (RARC) based on variation in institutional, patient, and disease characteristics to help in operating room scheduling and quality control.

PATIENTS AND METHODS: The model included preoperative variables and therefore can be used for prediction of surgical times: institutional volume, age, gender, body mass index, American Society of Anesthesiologists score, history of prior surgery and radiation, clinical stage, neoadjuvant chemotherapy, type, technique of diversion, and the extent of lymph node dissection. A conditional inference tree method was used to fit a binary decision tree predicting operative time. Permutation tests were performed to determine the variables having the strongest association with surgical time. The data were split at the value of this variable resulting in the largest difference in means for the surgical time across the split. This process was repeated recursively on the resultant data sets until the permutation tests showed no significant association with operative time.

RESULTS: In all, 2 134 procedures were included. The variable most strongly associated with surgical time was type of diversion, with ileal conduits being 70 min shorter (P < 0.001). Amongst patients who received neobladders, the type of lymph node dissection was also strongly associated with surgical time. Amongst ileal conduit patients, institutional surgeon volume (>66 RARCs) was important, with those with a higher volume being 55 min shorter (P < 0.001). The regression tree output was in the form of box plots that show the median and ranges of surgical times according to the patient, disease, and institutional characteristics.

CONCLUSION: We developed a method to estimate operative times for RARC based on patient, disease, and institutional metrics that can help operating room scheduling for RARC.

PURPOSE: Comprehensive training and skill acquisition by urological surgeons are vital to optimize surgical outcomes and patient safety. We sought to develop and validate PACE (Prostatectomy Assessment and Competence Evaluation), an objective and procedure specific tool to assess the quality of robot-assisted radical prostatectomy.

MATERIALS AND METHODS: Development and content validation of PACE was performed by deconstructing robot-assisted radical prostatectomy into 7 key domains utilizing the Delphi methodology. Reliability and construct validation were then assessed using de-identified videos performed by practicing surgeons and fellows. Consensus for each domain was defined as achieving a content validity index of 0.75 or greater. Reliability was assessed by the intraclass correlation and construct validation using a mixed linear model accounting for multiple ratings on the same video.

RESULTS: After 3 rounds consensus was reached on wording, relevance of the skills assessed and concordance between the score assigned and the skill assessed. An intraclass correlation of 0.4 or greater was achieved for all domains. The expert group outperformed trainees in all domains but reached statistical significance in bladder drop (4.5 vs 3.4, p = 0.002), preparation of the prostate (4.4 vs 3.2, p <0.0001), seminal vesicle and posterior plane dissection (8.3 vs 6.8, p = 0.03), and neurovascular bundle preservation (4.1 vs 2.4, p <0.0001). Limitations included the lack of assessment of other key skills such as communication and decision making.

CONCLUSIONS: PACE is a structured, procedure specific and reliable tool that objectively measures surgical performance during robot-assisted radical prostatectomy. It can differentiate different levels of expertise and provide structured feedback to customize training and surgical quality improvement.

OBJECTIVES: To develop a scoring tool, Pelvic Lymphadenectomy Appropriateness and Completion Evaluation (PLACE), to assess the intraoperative completeness and appropriateness of pelvic lymph node dissection (PLND) following robot-assisted radical cystectomy (RARC).

PATIENTS, SUBJECTS AND METHODS: A panel of 11 open and robotic surgeons developed the content and structure of PLACE. The PLND template was divided into three zones. In all, 21 de-identified videos of bilateral robot-assisted PLNDs were assessed by the 11 experts using PLACE to determine inter-rater reliability. Lymph node (LN) clearance was defined as the proportion of cleared LNs from all PLACE zones. We investigated the correlation between LN clearance and LN count. Then, we compared the LN count of 18 prospective PLNDs using PLACE with our retrospective series performed using the extended template (No PLACE).

RESULTS: A significant reliability was achieved for all PLACE zones among the 11 raters for the 21 bilateral PLND videos. The median (interquartile range) for LN clearance was 468 (431-545). There was a significant positive correlation between LN clearance and LN count (R2 = 0.70, P < 0.01). The PLACE group yielded similar LN counts when compared to the No PLACE group.

CONCLUSIONS: Pelvic Lymphadenectomy Appropriateness and Completion Evaluation is a structured intraoperative scoring system that can be used intraoperatively to measure and quantify PLND for quality control and to facilitate training during RARC.

PURPOSE: We sought to investigate the prevalence and variables associated with early oncologic failure.

MATERIALS AND METHODS: We retrospectively reviewed the IRCC (International Radical Cystectomy Consortium) database of patients who underwent robot-assisted radical cystectomy since 2003. The final cohort comprised a total of 1,894 patients from 23 institutions in 11 countries. Early oncologic failure was defined as any disease relapse within 3 months of robot-assisted radical cystectomy. All institutions were surveyed for the pneumoperitoneum pressure used, breach of oncologic surgical principles, and techniques of specimen and lymph node removal. A multivariate model was fit to evaluate predictors of early oncologic failure. The Kaplan-Meier method was applied to depict disease specific and overall survival, and Cox proportional regression analysis was used to evaluate predictors of disease specific and overall survival.

RESULTS: A total of 305 patients (22%) experienced disease relapse, which was distant in 220 (16%), local recurrence in 154 (11%), peritoneal carcinomatosis in 17 (1%) and port site recurrence in 5 (0.4%). Early oncologic failure developed in 71 patients (5%) at a total of 10 institutions. The incidence of early oncologic failure decreased from 10% in 2006 to 6% in 2015. On multivariate analysis the presence of any complication (OR 2.87, 95% CI 1.38-5.96, p = 0.004), pT3 or greater disease (OR 3.73, 95% CI 2.00-6.97, p <0.001) and nodal involvement (OR 2.14, 95% CI 1.21-3.80, p = 0.008) was a significant predictor of early oncologic failure. Patients with early oncologic failure demonstrated worse disease specific and overall survival (23% and 13%, respectively) at 1 and 3 years compared to patients who experienced later or no recurrences (log rank p <0.001).

CONCLUSIONS: The incidence of early oncologic failure following robot-assisted radical cystectomy has decreased with time. Disease related rather than technical related factors have a major role in early oncologic failure after robot-assisted radical cystectomy.

PURPOSE OF REVIEW: The aim of this study is to provide an overview of the current status of novel cognitive training approaches in surgery and to investigate the potential role of cognitive training in surgical education.

RECENT FINDINGS: Kinematics of end-effector trajectories, as well as cognitive state features of surgeon trainees and mentors have recently been studied as modalities to objectively evaluate the expertise level of trainees and to shorten the learning process. Virtual reality and haptics also have shown promising in research results in improving the surgical learning process by providing feedback to the trainee.

SUMMARY: 'Cognitive training' is a novel approach to enhance training and surgical performance. The utility of cognitive training in improving motor skills in other fields, including sports and rehabilitation, is promising enough to justify its utilization to improve surgical performance. However, some surgical procedures, especially ones performed during human-robot interaction in robot-assisted surgery, are much more complicated than sport and rehabilitation. Cognitive training has shown promising results in surgical skills-acquisition in complicated environments such as surgery. However, these methods are mostly developed in research groups using limited individuals. Transferring this research into the clinical applications is a demanding challenge. The aim of this review is to provide an overview of the current status of these novel cognitive training approaches in surgery and to investigate the potential role of cognitive training in surgical education.

OBJECTIVE: To describe a detailed step-by-step approach of our technique for robot-assisted intracorporeal 'W'-configuration orthotopic ileal neobladder.

PATIENTS AND METHODS: Five patients underwent robot-assisted radical cystectomy (RARC), extended pelvic lymph node dissection and intracorporeal neobladder (ICNB). ICNB was divided into six key steps to facilitate and enable a detailed analysis and auditing of the technique. No conversion to open surgery was required. Timing for each step was noted. All patients had at least 3 months of follow-up.

RESULTS: The mean age was 57 years. The mean overall console and diversion times were 357 and 193 min, respectively. None of the patients had any evidence of residual disease after RARC. Four of the five patients had complications; three developed fevers due to urinary tract infections (one required readmission), and one developed myocardial infarction and required coronary angiography and stenting. Looking at the timing for the individual steps, bowel detubularisation and construction of the posterior plate were consistently the longest among the key steps (average 46 min, 13% of the overall operative time), followed by uretero-ileal anastomosis (37 min, 10%), neobladder-urethral anastomosis (23 min, 6%), and identification and fixation of the bowel (26 min, 7%).

CONCLUSION: We described our step-by-step technique and initial perioperative outcomes of our first five ICNBs with 'W' configuration.

STUDY OBJECTIVE: To develop and validate a procedure-specific scoring algorithm to objectively measure robotic surgical skills during robot-assisted hysterectomy and to facilitate robotic surgery training and education.

DESIGN: (Canadian Task Force classification III).

SETTING: A National Comprehensive Cancer Network-designated comprehensive cancer center.

PATIENTS: Deidentified videos for robot-assisted hysterectomies were evaluated.

INTERVENTIONS: Videos from 26 robotic hysterectomies performed by surgeons with varying degrees of experience using the scoring system were evaluated. In phase I, critical elements of a robotic hysterectomy were deconstructed into 6 key domains to assess technical skills for procedure completion. Anchor descriptions were developed for each domain to match a 5-point Likert scale. Delphi methodology was used for content validation. A panel of 5 expert robotic surgeons refined this scoring system. In phase II, video recordings of procedures performed by surgeons with varying degrees of experience (expert, advanced beginner, and novice) were evaluated by blinded expert reviewers using the scoring system. Descriptive statistics were used to summarize the scores for each domain. Intraclass correlation was used to determine the interrater reliability. A p value <.05 was considered significant.

MEASUREMENTS AND MAIN RESULTS: The average score for the 3 classes of surgeon was 75.6 for expert, 71.3 for advanced beginner, and 69.0 for novice (p = .006). There were significant differences in scores of most individual domains among the various classes of surgeons. Novice surgeons took significantly longer than expert surgeons to complete their half of a hysterectomy (22.2 vs 12.0 minutes; p = .001).

CONCLUSION: This pilot study demonstrates the feasibility of using a standardized rubric for clinical skills assessment in robotic hysterectomy. Blinded expert reviewers were able to differentiate between varying levels of surgical experience using this assessment tool.

STUDY OBJECTIVE: To develop and validate a procedure-specific scoring algorithm to objectively measure robotic surgical skills during robot-assisted hysterectomy and to facilitate robotic surgery training and education.

DESIGN: (Canadian Task Force classification III).

SETTING: A National Comprehensive Cancer Network-designated comprehensive cancer center.

PATIENTS: Deidentified videos for robot-assisted hysterectomies were evaluated.

INTERVENTIONS: Videos from 26 robotic hysterectomies performed by surgeons with varying degrees of experience using the scoring system were evaluated. In phase I, critical elements of a robotic hysterectomy were deconstructed into 6 key domains to assess technical skills for procedure completion. Anchor descriptions were developed for each domain to match a 5-point Likert scale. Delphi methodology was used for content validation. A panel of 5 expert robotic surgeons refined this scoring system. In phase II, video recordings of procedures performed by surgeons with varying degrees of experience (expert, advanced beginner, and novice) were evaluated by blinded expert reviewers using the scoring system. Descriptive statistics were used to summarize the scores for each domain. Intraclass correlation was used to determine the interrater reliability. A p value <.05 was considered significant.

MEASUREMENTS AND MAIN RESULTS: The average score for the 3 classes of surgeon was 75.6 for expert, 71.3 for advanced beginner, and 69.0 for novice (p = .006). There were significant differences in scores of most individual domains among the various classes of surgeons. Novice surgeons took significantly longer than expert surgeons to complete their half of a hysterectomy (22.2 vs 12.0 minutes; p = .001).

CONCLUSION: This pilot study demonstrates the feasibility of using a standardized rubric for clinical skills assessment in robotic hysterectomy. Blinded expert reviewers were able to differentiate between varying levels of surgical experience using this assessment tool.

INTRODUCTION: To describe a detailed step-by-step approach of our technique to robot-assisted intracorporeal "W" orthotopic ileal neobladder (ICNB).

METHODS: Five patients underwent robot-assisted radical cystectomy (RARC), extended pelvic lymph node dissection (ePLND) and ICNB. ICNB was divided into 6 key steps to facilitate and enable a detailed analysis and auditing of the technique. No conversion to open surgery was required. Timing for each step was noted. All patients had at least 3 months of follow up.

RESULTS: Mean age was 57 years. Mean overall console and diversion times were 357 and 193 minutes, respectively. None of the patients had any evidence of residual disease following RARC. Four of five patients experienced complications; 3 developed fevers due to urinary tract infection (one required readmission), and 1 patient developed myocardial infarction and required coronary angiography and stenting. Looking at the timing for the individual steps, bowel detubularization and construction of posterior plate were consistently the longest among the key steps (average 46 minutes, 13% of the overall operative time), followed by uretero-ileal anastomosis (37 minutes, 10%), neobladder-urethral anastomosis (23 minutes, 6%) and identification and fixation of the bowel (26 minutes, 7%).

CONCLUSION: We described our step-by-step technique and initial perioperative outcomes of our first five intracorporeal neobladders with "W" configuration This article is protected by copyright. All rights reserved.

OBJECTIVES: To evaluate the effect of suboptimal dosing on the outcomes of patients who received neoadjuvant chemotherapy (NAC) and robot-assisted radical cystectomy (RARC).

PATIENTS AND METHODS: We retrospectively reviewed 336 consecutive patients with urothelial carcinoma of the bladder who were treated with NAC and RARC at three academic institutions. Outcomes were compared among three groups: patients who received optimal NAC; patients who received suboptimal NAC; and those who did not receive NAC. To adjust for potential baseline differences between the three groups, propensity-score-based matching was performed. The suboptimal dose group was defined as those who received <3 cycles of cisplatin-based chemotherapy, received a decreased dosage, or those not treated with cisplatin. Primary outcomes analysed were recurrence-free survival (RFS) and overall survival (OS). Secondary outcomes were peri-operative complications and readmissions after RARC.

RESULTS: After propensity-score matching, 69 patients in the cohort received optimal-dose NAC, 41 received suboptimal NAC and 69 did not receive NAC. Complication rates and readmission rates did not differ significantly among the three groups. On multivariable analysis, suboptimal NAC and no NAC were independent predictors of worse RFS (hazard ratio [HR] 2.5, 95% confidence interval [CI] 1.2-5.7, P = 0.01 and HR 2.4, 95% CI 1.28-5.16, P = 0.01) and worse OS (HR 4.5, 95% CI 1.6-15.0, P < 0.01 and HR 4.9, 95% CI 1.9-15.6, P < 0.01) in patients who received NAC and RARC. Failure to achieve pathological complete response (ypT0N0) was also an independent predictor of worse RFS (HR 6.6, 95% CI 1.3-20.9; P = 0.02) and OS (HR 4.9, 95% CI 1.8-15.3; P = 0.02).

CONCLUSION: Optimal NAC resulted in a better RFS and OS when compared with suboptimal or no NAC. Suboptimal and no NAC were associated with worse OS and RFS. These findings will facilitate improved patient counseling and treatment selection.

OBJECTIVES: To design a methodology to predict operative times for robot-assisted radical cystectomy (RARC) based on variation in institutional, patient, and disease characteristics to help in operating room scheduling and quality control.

PATIENTS AND METHODS: The model included preoperative variables and therefore can be used for prediction of surgical times: institutional volume, age, gender, body mass index, American Society of Anesthesiologists score, history of prior surgery and radiation, clinical stage, neoadjuvant chemotherapy, type, technique of diversion, and the extent of lymph node dissection. A conditional inference tree method was used to fit a binary decision tree predicting operative time. Permutation tests were performed to determine the variables having the strongest association with surgical time. The data were split at the value of this variable resulting in the largest difference in means for the surgical time across the split. This process was repeated recursively on the resultant data sets until the permutation tests showed no significant association with operative time.

RESULTS: In all, 2 134 procedures were included. The variable most strongly associated with surgical time was type of diversion, with ileal conduits being 70 min shorter (P < 0.001). Amongst patients who received neobladders, the type of lymph node dissection was also strongly associated with surgical time. Amongst ileal conduit patients, institutional surgeon volume (>66 RARCs) was important, with those with a higher volume being 55 min shorter (P < 0.001). The regression tree output was in the form of box plots that show the median and ranges of surgical times according to the patient, disease, and institutional characteristics.

CONCLUSION: We developed a method to estimate operative times for RARC based on patient, disease, and institutional metrics that can help operating room scheduling for RARC.

OBJECTIVE: To investigate cognitive and mental workload assessments, which may play a critical role in defining successful mentorship.

MATERIALS AND METHODS: The 'Mind Maps' project aimed at evaluating cognitive function with regard to surgeon's expertise and trainee's skills. The study included electroencephalogram (EEG) recordings of a mentor observing trainee surgeons in 20 procedures involving extended lymph node dissection (eLND) or urethrovesical anastomosis (UVA), with simultaneous assessment of trainees using the National Aeronautics and Space Administration Task Load index (NASA-TLX) questionnaire. We also compared the brain activity of the mentor during this study with his own brain activity while actually performing the same surgical steps from previous procedures populated in the 'Mind Maps' project.

RESULTS: During eLND and UVA, when the mentor thought the trainee's mental demand and effort were low based on his NASA-TLX questionnaire (not satisfied with his performance), his EEG-based mental workload increased (reflecting more concern and attention). The mentor was mentally engaged and concerned while he was engrossed in observing the surgery. This was further supported by the finding that there was no significant difference in the mental demands and workload between observing and operating for the expert surgeon.

CONCLUSIONS: This study objectively evaluated the cognitive engagement of a surgical mentor teaching technical skills during surgery. The study provides a deeper understanding of how surgical teaching actually works and opens new horizons for assessment and teaching of surgery. Further research is needed to study the feasibility of this novel concept in assessment and guidance of surgical performance.

OBJECTIVE: To investigate cognitive and mental workload assessments, which may play a critical role in defining successful mentorship.

MATERIALS AND METHODS: The 'Mind Maps' project aimed at evaluating cognitive function with regard to surgeon's expertise and trainee's skills. The study included electroencephalogram (EEG) recordings of a mentor observing trainee surgeons in 20 procedures involving extended lymph node dissection (eLND) or urethrovesical anastomosis (UVA), with simultaneous assessment of trainees using the National Aeronautics and Space Administration Task Load index (NASA-TLX) questionnaire. We also compared the brain activity of the mentor during this study with his own brain activity while actually performing the same surgical steps from previous procedures populated in the 'Mind Maps' project.

RESULTS: During eLND and UVA, when the mentor thought the trainee's mental demand and effort were low based on his NASA-TLX questionnaire (not satisfied with his performance), his EEG-based mental workload increased (reflecting more concern and attention). The mentor was mentally engaged and concerned while he was engrossed in observing the surgery. This was further supported by the finding that there was no significant difference in the mental demands and workload between observing and operating for the expert surgeon.

CONCLUSIONS: This study objectively evaluated the cognitive engagement of a surgical mentor teaching technical skills during surgery. The study provides a deeper understanding of how surgical teaching actually works and opens new horizons for assessment and teaching of surgery. Further research is needed to study the feasibility of this novel concept in assessment and guidance of surgical performance.

OBJECTIVES: To evaluate the effect of suboptimal dosing on the outcomes of patients who received neoadjuvant chemotherapy (NAC) and robot-assisted radical cystectomy (RARC).

PATIENTS AND METHODS: We retrospectively reviewed 336 consecutive patients with urothelial carcinoma of the bladder who were treated with NAC and RARC at three academic institutions. Outcomes were compared among three groups: patients who received optimal NAC; patients who received suboptimal NAC; and those who did not receive NAC. To adjust for potential baseline differences between the three groups, propensity-score-based matching was performed. The suboptimal dose group was defined as those who received <3 cycles of cisplatin-based chemotherapy, received a decreased dosage, or those not treated with cisplatin. Primary outcomes analysed were recurrence-free survival (RFS) and overall survival (OS). Secondary outcomes were peri-operative complications and readmissions after RARC.

RESULTS: After propensity-score matching, 69 patients in the cohort received optimal-dose NAC, 41 received suboptimal NAC and 69 did not receive NAC. Complication rates and readmission rates did not differ significantly among the three groups. On multivariable analysis, suboptimal NAC and no NAC were independent predictors of worse RFS (hazard ratio [HR] 2.5, 95% confidence interval [CI] 1.2-5.7, P = 0.01 and HR 2.4, 95% CI 1.28-5.16, P = 0.01) and worse OS (HR 4.5, 95% CI 1.6-15.0, P < 0.01 and HR 4.9, 95% CI 1.9-15.6, P < 0.01) in patients who received NAC and RARC. Failure to achieve pathological complete response (ypT0N0) was also an independent predictor of worse RFS (HR 6.6, 95% CI 1.3-20.9; P = 0.02) and OS (HR 4.9, 95% CI 1.8-15.3; P = 0.02).

CONCLUSION: Optimal NAC resulted in a better RFS and OS when compared with suboptimal or no NAC. Suboptimal and no NAC were associated with worse OS and RFS. These findings will facilitate improved patient counseling and treatment selection.

PURPOSE: Comprehensive training and skill acquisition by urological surgeons are vital to optimize surgical outcomes and patient safety. We sought to develop and validate PACE (Prostatectomy Assessment and Competence Evaluation), an objective and procedure specific tool to assess the quality of robot-assisted radical prostatectomy.

MATERIALS AND METHODS: Development and content validation of PACE was performed by deconstructing robot-assisted radical prostatectomy into 7 key domains utilizing the Delphi methodology. Reliability and construct validation were then assessed using de-identified videos performed by practicing surgeons and fellows. Consensus for each domain was defined as achieving a content validity index of 0.75 or greater. Reliability was assessed by the intraclass correlation and construct validation using a mixed linear model accounting for multiple ratings on the same video.

RESULTS: After 3 rounds consensus was reached on wording, relevance of the skills assessed and concordance between the score assigned and the skill assessed. An intraclass correlation of 0.4 or greater was achieved for all domains. The expert group outperformed trainees in all domains but reached statistical significance in bladder drop (4.5 vs 3.4, p = 0.002), preparation of the prostate (4.4 vs 3.2, p <0.0001), seminal vesicle and posterior plane dissection (8.3 vs 6.8, p = 0.03), and neurovascular bundle preservation (4.1 vs 2.4, p <0.0001). Limitations included the lack of assessment of other key skills such as communication and decision making.

CONCLUSIONS: PACE is a structured, procedure specific and reliable tool that objectively measures surgical performance during robot-assisted radical prostatectomy. It can differentiate different levels of expertise and provide structured feedback to customize training and surgical quality improvement.

OBJECTIVE: To develop quality assessment tool to evaluate surgical performance for robot-assisted radical cystectomy program.

METHODS: A prospectively maintained quality assurance database of 425 consecutive robot-assisted radical cystectomies performed by a single surgeon between 2005 and 2015 was retrospectively reviewed. Potentially modifiable factors, related to the management and perioperative care of patients, were used to evaluate patient care. Criteria included the following: preoperative (administration of neoadjuvant chemotherapy); operative (operative time <6.5 hours and estimated blood loss <500 cc); pathologic (negative soft tissue surgical margins and lymph node yield ≥20); and postoperative (no high-grade complications, readmission, or noncancer-related mortality within 30 days).The Quality Cystectomy Score (QCS) was developed (1 star: achieving ≤2 criteria or mortality within 30 days; 2 stars: 3 or 4 criteria met; 3 stars: 5 or 6 criteria met; and 4 stars: 7 or all criteria met). Univariate and multivariate Cox proportional hazard regression models were fitted to test for the association between QCS and survival outcomes.

RESULTS: Most patients (85%) achieved at least 3 stars, and more patients achieved 4 stars with time. High QCS was associated with better recurrence-free, cancer-specific, and overall survival (P values <.05). None of the patients with 1-star were alive at 1 year. Patients with 4 stars achieved the best survival rates (recurrence-free survival [62%], cancer-specific survival [70%], and overall survival [53%] at 5 years) (log rank P < .0001).

CONCLUSION: Continuous assessment for quality improvement facilitated implementation and maintenance of robot-assisted program for bladder cancer.

OBJECTIVES: To design a data collection methodology to capture team activities during robot-assisted surgery (RAS) (team communications, surgical flow, and procedural interruptions), and use relevant disciplines of Industrial Engineering and Human Factors Engineering to uncover key issues impeding surgical flow and guide evidence-based strategic changes to enhance surgical performance and improve outcomes.

DESIGN: Field study, to determine the feasibility of the proposed methodology.

SETTING: Recording the operating room (OR) environment during robot-assisted surgeries (RAS). The data collection system included recordings from the console and 3 aerial cameras, in addition to 8 lapel microphones (1 for each OR team member). Questionnaires on team familiarity and cognitive load were collected.

PARTICIPANTS: In all, 37 patients and 89 OR staff members have consented to participate in the study.

RESULTS: Overall, 37 RAS procedures were recorded (130 console hours). A pilot procedure was evaluated in detail. We were able to characterize team communications in terms of flow, mode, topic, and form. Surgical flow was evaluated in terms of duration, location, personnel involved, purpose, and if movements were avoidable or not. Procedural interruptions were characterized according to their duration, cause, mode of communication, and personnel involved.

CONCLUSION: This methodology allowed for the capture of a wide variety of team activities during RAS that would serve as a solid platform to improve nontechnical aspects of RAS.

OBJECTIVES: To design a data collection methodology to capture team activities during robot-assisted surgery (RAS) (team communications, surgical flow, and procedural interruptions), and use relevant disciplines of Industrial Engineering and Human Factors Engineering to uncover key issues impeding surgical flow and guide evidence-based strategic changes to enhance surgical performance and improve outcomes.

DESIGN: Field study, to determine the feasibility of the proposed methodology.

SETTING: Recording the operating room (OR) environment during robot-assisted surgeries (RAS). The data collection system included recordings from the console and 3 aerial cameras, in addition to 8 lapel microphones (1 for each OR team member). Questionnaires on team familiarity and cognitive load were collected.

PARTICIPANTS: In all, 37 patients and 89 OR staff members have consented to participate in the study.

RESULTS: Overall, 37 RAS procedures were recorded (130 console hours). A pilot procedure was evaluated in detail. We were able to characterize team communications in terms of flow, mode, topic, and form. Surgical flow was evaluated in terms of duration, location, personnel involved, purpose, and if movements were avoidable or not. Procedural interruptions were characterized according to their duration, cause, mode of communication, and personnel involved.

CONCLUSION: This methodology allowed for the capture of a wide variety of team activities during RAS that would serve as a solid platform to improve nontechnical aspects of RAS.

OBJECTIVE: To analyze and categorize causes for interruptions during robot-assisted surgery.

METHODS: We analyzed 10 robot-assisted prostatectomies that were performed by 3 surgeons from October 2014 to June 2015. Interruptions to surgery were defined in terms of duration, stage of surgery, personnel involved, reasons, and impact of the interruption on the surgical workflow.

RESULTS: The main reasons for interruptions included the following: console surgeons switching (29%); preparation of the surgical equipment, such as cleaning or changing the camera (29%) or an instrument (27%); or when a suture, stapler, or clip was needed (12%). The most common interruption duration was 10-29 seconds (47.6%), and the least common interruption duration was greater than 90 seconds (3.6%). Additionally, about 14% of the interruptions were considered avoidable, whereas the remaining 86% of interruptions were necessary for surgery.

CONCLUSION: By identifying and analyzing interruptions, we can develop evidence-based strategies to improve operating room efficiency, lower costs, and advance patient safety.

OBJECTIVE: To analyze and categorize causes for interruptions during robot-assisted surgery.

METHODS: We analyzed 10 robot-assisted prostatectomies that were performed by 3 surgeons from October 2014 to June 2015. Interruptions to surgery were defined in terms of duration, stage of surgery, personnel involved, reasons, and impact of the interruption on the surgical workflow.

RESULTS: The main reasons for interruptions included the following: console surgeons switching (29%); preparation of the surgical equipment, such as cleaning or changing the camera (29%) or an instrument (27%); or when a suture, stapler, or clip was needed (12%). The most common interruption duration was 10-29 seconds (47.6%), and the least common interruption duration was greater than 90 seconds (3.6%). Additionally, about 14% of the interruptions were considered avoidable, whereas the remaining 86% of interruptions were necessary for surgery.

CONCLUSION: By identifying and analyzing interruptions, we can develop evidence-based strategies to improve operating room efficiency, lower costs, and advance patient safety.

OBJECTIVE: To analyse ambulatory movements and team dynamics during robot-assisted surgery (RAS), and to investigate whether congestion of the physical space associated with robotic technology led to workflow challenges or predisposed to errors and adverse events.

METHODS: With institutional review board approval, we retrospectively reviewed 10 recorded robot-assisted radical prostatectomies in a single operating room (OR). The OR was divided into eight zones, and all movements were tracked and described in terms of start and end zones, duration, personnel and purpose. Movements were further classified into avoidable (can be eliminated/improved) and unavoidable (necessary for completion of the procedure).

RESULTS: The mean operating time was 166 min, of which ambulation constituted 27 min (16%). A total of 2 896 ambulatory movements were identified (mean: 290 ambulatory movements/procedure). Most of the movements were procedure-related (31%), and were performed by the circulating nurse. We identified 11 main pathways in the OR; the heaviest traffic was between the circulating nurse zone, transit zone and supply-1 zone. A total of 50% of ambulatory movements were found to be avoidable.

CONCLUSION: More than half of the movements during RAS can be eliminated with an improved OR setting. More studies are needed to design an evidence-based OR layout that enhances access, workflow and patient safety.

OBJECTIVE: To analyze ambulatory movements and team dynamics during robot-assisted surgery (RAS), and investigate whether congestion of the physical space associated with RA technology led to workflow challenges, or predisposed to errors and adverse events.

METHODS: With IRB approval, we retrospectively reviewed 10 recorded RA radical prostatectomies in a single operating room (OR). OR was divided into 8 zones, and all movement were tracked and described in terms of start and end zones, duration, personnel, and purpose. Movement were further classified into avoidable (can be eliminated/improved) and unavoidable (necessary for completion of the procedure).

RESULTS: Mean operative time was 166 minutes, of which ambulation constituted 27 minutes (16%). A total of 2,896 ambulatory movements were identified (mean=290 ambulatory movements/procedure). Most of movements were procedure-related (31%), and were performed by the circulating nurse. We identified 11 main pathways in the OR (Figure 1); the heaviest traffic was between the Circulating Nurse Zone, Transit Zone and Supply-1 Zone.Fifty percent of ambulatory movements were found to be avoidable.

CONCLUSION: More than half of the movements during RAS can be eliminated with an improved OR setting. More studies are needed to design an evidence-based OR layout that enhances access, workflow and patient safety. This article is protected by copyright. All rights reserved.