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

Abstract

Objective: Surgical 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.

Methods: Intraoperative 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.

Results: Stomach 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).

Conclusions: A 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.

Keywords: objective performance indicators; robotic-assisted surgery; sleeve gastrectomy; surgical task; video analytics; workflow analysis.

Figure 1

Procedure workflow changes over years. Segmented tasks from 9 example cases. Hiatal hernia dissection and repair were excluded from further analysis. Surgical inactivity time was denoted as the gaps between tasks.

Figure 2

Trend in task duration change of all 77 cases over five years.

Figure 3

Correlation plot between BMI, task durations and procedure duration. Regression lines are included for each sub-comparison. The 95% confidence intervals were shown as the translucent bands around the regression line. Distributions of (A) BMI, (B) stomach dissection, (C) place bougie, (D) stomach stapling, (E) leak test, (F) surgical inactivity with regard to procedure durations are included for earlier and later case groups, respectively.

Figure 4

Stomach dissection OPIs between earlier and later case groups. Comparisons between earlier and later cases groups were provided for OPIs: (A) energy activation rate, (B) energy activation median duration, (C) arm swap rate, (D) camera movement rate, (E) camera movement median duration.