Identification of Main Influencers of Surgical Efficiency and Variability Using Task-Level Objective Metrics: A Five-Year Robotic Sleeve Gastrectomy Case Series

Abstract

ObjectiveSurgical efficiency and variability are critical contributors to optimal outcomes, patient experience, care team experience, and total cost to treat per disease episode. Opportunities remain to develop scalable, objective methods to quantify surgical behaviors that maximize efficiency and reduce variability. Such objective measures can then be used to provide surgeons with timely and user-specific feedbacks to monitor performances and facilitate training and learning. In this study, we used objective task-level analysis to identify dominant contributors toward surgical efficiency and variability across the procedural steps of robotic-assisted sleeve gastrectomy (RSG) over a five-year period for a single surgeon. These results enable actionable insights that can both complement those from population level analyses and be tailored to an individual surgeon's practice and experience.MethodsIntraoperative video recordings of 77 RSG procedures performed by a single surgeon from 2015 to 2019 were reviewed and segmented into surgical tasks. Surgeon-initiated events when controlling the robotic-assisted surgical system were used to compute objective metrics. A series of multi-staged regression analysis were used to determine: if any specific tasks or patient body mass index (BMI) statistically impacted procedure duration; which objective metrics impacted critical task efficiency; and which task(s) statistically contributed to procedure variability.ResultsStomach dissection was found to be the most significant contributor to procedure duration (β = 0.344, p< 0.001; R = 0.81, p< 0.001) followed by surgical inactivity and stomach stapling. Patient BMI was not found to be statistically significantly correlated with procedure duration (R = −0.01, p = 0.90). Energy activation rate, a robotic system event-based metric, was identified as a dominant feature in predicting stomach dissection duration and differentiating earlier and later case groups. Reduction of procedure variability was observed between earlier (2015-2016) and later (2017-2019) groups (IQR = 14.20 min vs. 6.79 min). Stomach dissection was found to contribute most to procedure variability (β = 0.74, p < 0.001).ConclusionsA surgical task-based objective analysis was used to identify major contributors to surgical efficiency and variability. We believe this data-driven method will enable clinical teams to quantify surgeon-specific performance and identify actionable opportunities focused on the dominant surgical tasks impacting overall procedure efficiency and consistency.

Ratio of Economy of Motion: A New Objective Performance Indicator to Assign Consoles During Dual-Console Robotic Proctectomy

“…Surgical data science, the field that has emerged from the analysis of OPIs, is young but includes exciting preliminary work in urology, general surgery, bariatrics, and thoracic surgery. 1,5,6 Early studies of OPIs (in previous literature referred to as automated performance metrics or objective performance metrics) came from laboratory and virtual environments. Fard et al 7 reported the use of machine learning analysis of OPIs during knot tying and suturing to predict surgeon expertise with >90% accuracy with immediate feedback.…”

“…Surgical data science, the field that has emerged from the analysis of OPIs, is young but includes exciting preliminary work in urology, general surgery, bariatrics, and thoracic surgery. 1,5,6…”

“…3 In 2022, Tousignant et al utilized OPIs to objectively evaluate the progression of a single bariatric surgeon during 77 robotic-assisted sleeve gastrectomies over 5 years. 5 Annotation of the procedure into defined tasks allowed the authors to find a single task (stomach dissection) as the most significant contributor to procedure duration. One OPI, energy activation rate, was predictive of stomach stapling duration and differed significantly during early and later years.…”

“…1,2 Objective performance indicator analyses offer objective insights into surgeon training, movements, skill level, operation flow and complexity, and postoperative outcomes. [1][2][3][4][5][6][7] Analyses of OPI data are more difficult in dual-console procedures (DCPs, in which attending and trainee work from separate consoles), as there is currently no method to establish console dominance during individual surgical tasks. Consequently, this limits the ability to track a trainee's progression of task mastery over time.…”

Quantification of surgical workflow during robotic proctectomy

“…for partial nephrectomy, 10 Tousignant et al for sleeve gastrectomy, 11 and Metchik et al for lobectomy, 12 but no such work has been published for proctectomy. Through step segmentation, OPIs have enabled objective step-specific feedback to provide insights into surgical workflow, procedure complexity, surgeon skill and surgical outcomes.…”