Speed in Surgery

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Speed in operating should be rendhe achievement, not the aim, of every surgeon. – Russell John Howard

This old school howardism makes an excellent point: speed in surgery is the fruit of good technique, efficiency of motion, and a lack of complications. But the lust for speed may encourage risk taking and shortcut making resulting in poor surgery, longer surgery, and more complications.

Is the length of surgery important?

Yes. Better outcomes are consistently observed with shorter length of surgery.

However, the relationship between shorter surgery and better outcomes is complex. Are better outcomes the result of a shorter time, or is a shorter time the result of a simple, less moribund case? The answer is both. Shorter surgical time definitely translates into fewer complications due to the effect of the time itself. Shorter time means:

  • Less anesthesia exposure, and therefore fewer issues like nausea, delayed return to bowel and bladder function, pneumonia, etc.
  • Less time in a paralyzed, positioned state, translating into fewer cases of thromboembolism, fewer positional neuropathies, etc.
  • Less time with an open body cavity, leading to fewer infections, less sepsis, etc.

This study of about 100,000 surgical cases found that longer operating times were associated with an increased risk of urinary tract infections, organ-space surgical site infections, sepsis/septic shock, pneumonia, DVT, renal failure, wound disruption, cardiac arrest requiring CPR, and death. In fact, surgical site infections occurred in 14.1/1,000 cases per hour, starting at 42 minutes, and 16.6/1,000 cases of sepsis occurred for each additional hour longer than the standard time the case should take. A total of 116 per 1,000 additional negative outcomes were associated with each extra hour of surgery. By comparison, the fastest procedures (top 2.5%tile)  had the lowest composite rate of negative outcomes.

Of course, a shorter surgery is also a result of factors that naturally lead to shorter surgeries and produce better outcomes anyway, such as:

  • More proficient surgeons who perform better surgery.
  • Less complicated cases (and often less moribund patients) which are naturally going to take less time and have fewer complications.

This last point is cited as the reason why surgery takes too long by every surgeon who has ever had a long case (“The patient was complicated…”) or if a surgeon is consistently slow then it is because all of his patients are complicated. While there is obviously some truth to this, we must be careful not to blame the patient for our own inadequacies. Think about how well your best cases go with straightforward patients and compare those length of surgery times to some standard metrics.

A lot of focus today is on minimally invasive surgery as a means to decrease patient complications. Yet, length of surgery is often more important than the route of surgery. If minimally invasive approaches take considerably longer than open approaches (or result in more steep Trendelenburg, excessive abdominal insufflation, prolonged intubation, etc.) then a patient might be better served with an open approach. For example, once a laparoscopic total colectomy takes longer than 3 hours, then the patient would have had fewer total complications with an open procedure. The data is scarce, but one might assume the same to be true with hysterectomy. A robotic case that takes in excess of 3 hours with several ports, steep Trendelenburg position, and high insufflation pressures undoubtedly results in more morbidity than a 30 minute abdominal hysterectomy performed through an 8 cm incision (or a 20 minute vaginal hysterectomy performed through no incision).

So how long should surgeries take? 

As little time as possible to safely complete the task.

A more pragmatic answer is difficult. Scientific studies that report average lengths of surgery are often not comparable to the time we should expect a competent surgeon to take in the real world since most of the published cases are performed by residents in training programs. This question reminds me of a passage from Joel-Cohen’s book from the 1970s entitled Abdominal and Vaginal Hysterectomy: new techniques based on time and motion studies. Joel-Cohen published a treatise of his own surgical techniques which had been influenced by his own filmed and photographed studies looking for ways to improve efficiencies. He says:

Although speed as such is no criterion of the surgeon’s ability, with simplicity and constancy of technique, no waste of movements, and using instruments properly, there is an enormous saving of time. It is therefore necessary for me to say that, without hurrying, my own average time for abdominal hysterectomy, that is a total hysterectomy from skin opening to complete skin closure, is usually, about twenty to twenty-five minutes. Vaginal hysterectomy with repair, anterior and posterior, is also twenty to twenty-five minutes for the complete operation, and without repair, an average of twelve to fifteen minutes. These are recorded times and not guesses.

Well. He sounds like a fun party guest. But he is right.  Joel-Cohen was a master of his craft and was obviously reporting his straightforward cases, but still the times are realistic. I have done simple vaginal hysterectomies in just under 10 minutes but my average runs closer to 18 minutes (I have seen a video of a complete TVH in just 6 minutes). Routine cesareans should take between 12 and 18 minutes. Simple abdominal hysterectomies should take about 25 minutes or less. Additional procedures obviously add additional time, but even complicated cases can be performed in less than double these times.

I am not saying that Joel-Cohen operative times should be expected for the average gynecologist, but in non-teaching cases, the averages shouldn’t be considerably longer. Obviously a wide variation of lengths of surgery exists for different procedures. I know general surgeons who can do an appendectomy in 10 minutes and I know some who take considerably over an hour. Why the variation? If you can answer this question, you can understand how to become faster.

How can I become faster?

Let’s look at a few factors that contribute to shorter operative times (and better outcomes). At the outset, it should be stated clearly that speed is for the patient’s benefit, not the surgeon’s. Speed gains come from efficiency not haste.

1. Essentialism (simplicity). Simplicity of technique is the hallmark of good surgery. Not only does simplicity save time, but it also presents fewer steps wherein mistakes can occur, reduces the perceived technical complexity/difficulty of the procedure (boosting the surgeon’s self-efficacy) and allows for greater procedural simplicity. Einstein is often misquoted as saying, “Everything should be made as simple as possible, but not simpler.” This is one of the truest principles of surgical technique.

There are some essential features of every procedure; but for every essential procedure, there are often many unnecessary steps that have been added over time. Separating the essential steps from superfluous complexity is the sine qua non of great surgical technique. Leonardo da Vinci said, “Simplicity is the ultimate sophistication.” It’s ironic that a surgical robot was named after him.

What are the steps that must be done for any given surgery? Let’s think about cesarean delivery for a moment. The abdomen and uterus must be entered, the child and placenta delivered, and the uterus and abdomen closed. Now what are the best methods to accomplish each of those steps? For details about this procedure, read more here. But more to the point, What are the superfluous steps? Closure of the parietal and visceral peritoneum are unnecessary; sharp entry and dissection into the parietal and visceral peritoneum are unnecessary; dissection of the rectus muscles off of the rectus sheath are unnecessary; irrigation and manual dilation of the cervix are unnecessary; two-layer closure of the uterus is unnecessary; non-inclusion of the vesicouterine peritoneum into the hysterotomy closure is unnecessary; routinely grasping the uterine incision with various clamps before repair is unnecessary; routine cauterization of various areas with the Bovie is unnecessary; cleaning out the uterus with a sponge is unnecessary; and reapproximation of the rectus muscles is unnecessary.

Not only are all of these things unnecessary, but most have evidence of harm and all add time and complexity to the procedure, increasing the aggregate risk and rate of complications. All of these steps at one point were considered to be crucial to a successful surgery by someone, but we need to use whatever evidence we have available today to decide whether they are truly essential. All of the above steps have failed that test.

So how do you figure out which steps are essential? Think about every single step and the alternatives that exist for each step; then search for the evidence. A lot of surgeons just don’t know that there is another way – they have totally lost sight of what is essential and necessary and what is superfluous and harmful. Do you really need the arms tucked to do a 5 minute laparoscopic tubal ligation? Do you actually need a paracervical block to do an Essure? Do you routinely need to sound the uterus prior to inserting an IUD? What good is a left tilt during a cesarean? Why did you give a preoperative antibiotic to a patient having a diagnostic laparoscopy? Do you actually need a uterine manipulator to do a tubal? Do you need a robot to perform a hysterectomy? Question every step and eliminate the things that are not productive.

Custom and habit are not excuses for continuing to do things the way they were once done. I wrote recently about the many once-performed but not evidence based steps of a vaginal delivery. Similarly unnecessary steps exist for everything that we do.

Some steps may be necessary but more than one method exists for completing each step. For example, initial laparoscopic entry may be accomplished by direct entry with an optical trocar, pre-insufflation with a Veress needle, or an open method using a Hasson cannula. Which is safer? Direct entry (if this shocks you, it’s true). Which is faster? Direct entry. We can secure the pedicles during a hysterectomy with clamps and suture or with an energy sealing device. Which is safer? The energy sealing device. Which is faster? The energy sealing device. You will find that most of the time the faster method is also the safer method.

When we eliminate unnecessary steps from surgery, a common criticism is that we are being lazy or acting in haste. This criticism is based on the usually incorrect assumption that the eliminated step was valuable in the first place. For example, I don’t rip open the fascia and peritoneum during abdominal entry for a Cesarean because I am in hurry; I do it because it is associated with better patient outcomes. Remember, speed is the achievement of good surgery, not the goal. Isaac Newton said:

“Truth is ever to be found in simplicity, and not in the multiplicity and confusion of things.”

Our task is challenging only because surgery has evolved through trial and error over many decades and only recently has scientific evidence really weighed in. Procedures have accumulated unnecessary complexities. We must erase the prior assumptions and seek the essentials.

2. Confidence. One of my favorite books, Technique in the Use of Surgical Tools, by Romfh and Cramer, contains this pearl:

“The surgeon who terrorizes his operating team is advertising his inadequacies and lack of self-confidence.”

Self-confidence and self-efficacy are essential to a good surgeon. This is not the same as ego. I have written about self-efficacy here and factors that contribute to it. Many surgeons, for all their ego and brashness, lack self-efficacy. Arrogance is often a compensation for low self-esteem and low self-efficacy. What practical steps can you take to increase your sense of confidence and self-efficacy?

  • Learn as much as you can about your procedures. I have read hundreds of texts and articles describing vaginal hysterectomy technique spanning the last 170 years. Constant study and research are essential. Surgical videos are a huge advantage to modern surgeons; don’t just watch the good ones, though, also watch the bad ones. I have learned more from watching bad surgery than good surgery.
  • Learn anatomy very well. It may sound surprising to say, but many surgeons are very poor anatomists. The anterior colpotomy is one of the most difficult steps of any surgery for most gynecologists; yet most of the perceived difficulty comes from a lack of understanding of the anatomy. If you think you already know it, re-learn it.
  • Understand not just the “how” of the technique but the “why.” If you ask a person why they make a bladder flap at the time of cesarean, they will offer a variety of answers like “to protect the bladder” or “to expose the location for the hysterotomy.” Both of these reasons are wrong and neither were the intended reasons why bladder flaps were made initially more than 100 years ago. A better answer would be, “Because someone told me to always do it that way when I was a resident.” Many surgeons are completely clueless (even if they think they aren’t) about why they perform certain surgical steps, even if they know how to do them. I call this parroting. Don’t be a parrot. Learn why you do each step (and if there isn’t a reason, stop doing it).

A confident surgeon is a deliberate surgeon. If you know what you intend to do, do it! Too frequently surgeons “stutter and stammer” with the needle, unsure of themselves and unsure of their bites. Clamps are placed and replaced three or four times because the surgeon just isn’t sure of quite where it should be. A lack of repertoire in different techniques leads surgeons to keep trying the same thing over and over again, even though it’s not working, when the case becomes challenging. Uncertainty about simple anatomy leads surgeons to look and relook, consider and reconsider. If you know the starting point and the endpoint, you can draw a line between two dots as well as anyone; but too often, surgeons lack deliberateness because they are unsure of the goal and how best to get there. Make purposeful progress with every step. Be intentional.

3. Efficiency.

Joel-Cohen and other master surgeons talk a lot about efficiency of motion and proper utilization of tools. Here are some tips for both.

How can you improve your efficiency?

  • Film yourself. You can learn more about what you do well and what you do poorly by watching a video of yourself operating than by doing almost anything else.
  • Visualize. Mental visualization helps improve the performance of almost any skill. If you are truly fluent in doing a procedure, you should be able to close your eyes and see every step in your mind. How are you holding the needle driver? How is the needle loaded? Where is the tail of the suture? What is your assistant doing (and what can they do better to help you)? Even the smallest, most trivial parts of the procedure should be visualized and analyzed. All of those little details add up.
  • Assist others. When you assist others and try to anticipate and be helpful, you will learn a lot. Where does the surgeon struggle and why? What could be done differently? How can you (as the assistant) help them when they struggle, or help them be more efficient in general? This knowledge will make you a better surgeon, too.
  • Watch good surgery. In person, on videos, in other specialities – it doesn’t really matter. You will build your self-efficacy and surgical repertoire by watching others do surgery well.
  • Debrief at the end of a surgery. What steps did you struggle with and why? Are there things you can study or exercises you can do or techniques you can learn to make this better next time? Surgery on a live patient is the wrong place and time to learn intracorporeal knot-tying; these types of skills should be gained in simulated practice. Try to debrief with yourself or your assistant after every case with the goal of finding something to do better every time.

How can you better use tools? If you are a student of the history of surgery, then you realize that as new tools were developed, huge gains were made in safety, ease, and efficiency. Tools are our friends, and if you find yourself struggling, you probably aren’t using the right tool or you aren’t using the tool right.

  • Learn about various surgical instruments and look for opportunities to use them where they might not be traditionally used. I use the Yankauer suction tool (not hooked up to suction) to elevate the tube through a 1 cm incision at the time of postpartum tubal. It makes it really easy. I use the Jorgensen scissors during uterine morcellation (because they are sharp and curved) and during difficult posterior colpotomies at the time of vaginal hysterectomy (because of the acute angle). The trick of using the right angle clamp and Bovie to take down the uterosacral and cardinal ligaments during a non-descent vaginal hysterectomy is one of the greatest tricks I know. These and many more insights come from thinking a bit outside the box about how to use tools.
  • Take advantage of enabling technologies. I have written before about the use of enabling technologies like the Ligasure during vaginal hysterectomy or global endometrial ablation devices like Novasure. Embrace these enabling technologies; they don’t make you less of a surgeon, they make you a better surgeon. The needle driver is an enabling technology; can you imagine surgeons today refusing to use it and instead using only straight needles to do all of their cases? Enabling technologies make for safer and faster surgeries and they improve the surgeon’s self-efficacy and confidence.
  • Get the basics right before you venture off into technology, believing it can fix your poor surgery. A golfer with a poor swing is no better with an $800 driver than a $50 driver, just poorer. A robot is not the solution to poor surgical ability, just an expensive toy.

My mentor liked to say, “Surgery is a thousand little things done well.” There are lot of things that go into making surgery productive and efficient. A few seconds saved here and there add up to lots of time at the end. Anticipate where you’re going and go there with purpose; bring the team along with you and anticipate their needs. Ultimately, you are no better than your team. How do you make your team better? How do you make your assistant better? Give plenty of advanced notice to the scrub tech for what you need next. It takes time to open up additional suture, load a needle driver, get a scope hooked up, etc. Provide ample time and notice so that when you actually need something it is in your hand. Always see the next several steps in your mind so that you are drawing a straight line between the dots.

Lastly, error begets error. If you place a trocar through the inferior mesenteric artery because you don’t know the anatomy well, you’ve just added 15 or 20 minutes to the case. If your initial circumferential incision around the cervix is too distal, you’ve likely added 10 minutes to the case as you struggle to make colpotomies. If you make the incision too low on the uterus during a cesarean for a woman who has a deep arrest, you might have added 30 minutes to the case fixing an extension into the cervix, vagina, or bladder. Mistakes like these are not a product of haste; they are product of poor knowledge of anatomy and poor technique. Many surgeons are their own worst enemies. Avoiding missteps associated with poor technique is perhaps the greatest time-saver of all.