Duration of surgical procedures
The duration of a certain surgical procedure is often mentioned in the literature to document the complexity or simplicity of an operation, or the skill of the surgeons.
It is obvious that major procedures take more time while minor surgery should be shorter but what is long or short? Is it defined?
It is also well known that besides the skill of the surgeon and his experience with a specific operation other factors play a role in determining its duration. Is it an emergency procedure or an elective one? Does the surgeon operate by himself or guides n resident? Is he assisted by competent surgical assistants or by other health professional?
We assume, however, that major elective procedures published in the literature are performed in leading centers under optimal conditions. Why then is the reported duration of operation so variable. For example the mean duration of the Whipple procedure varies between 4 to 8 hours in the different series; palliative bypass for obstructive jaundice is performed by some in 2 hours while others take a mean of 6 hours…Why is it so?
There must be some “cultural” reasons which provide the impetus for surgeons in one country to be “fast” and surgeons in another country to be “slow”. One such possible reason is the OR and Department of Anesthesia. In some countries the anesthetists are “interested” in “shorter” procedures: “to take the patient off the bed and go and have tea” . In other places the OR and anesthetists bill per hour or minute… ; “as long as the OR is busy the dollar clock ticks; so why hurry-let the surgeon operate and operate…”.
We know that too hasty operations are potentially hazardous, and that one can not adequately think or teach under excessive pressure to “finish”. On the other hand we know that excessive length has potential complications such as: hypothermia, DVT, atelectasis, wound infections, surgeon’s exhaustion and financial morbidity. So where is the balance? What is the optimal duration?
Hypothesis: there are drastic diferences in the mean duration of similar procedures published in the literature. The duration of operations differ in various countries reflecting tradition,culture, and (negative) financial pressures.
What do you think about this issue? Many of you worked in different countries or places and may have some thoughts to shade new light!
The issue is the one of the bluffing surgeon.
Duration of surgery is of value if it represents the development of a learning curve. In that case it may give some indication about how long it takes to master a certain procedure. Also if two procedures are compared duration may give some insight in their relative comlexity of simplicity.
In all other cases surgeons seem to believe that it is an indication of their skill if they are able to operate faster than others. I believe the contrary.
I myself am, undoubtedly, a slow operator. It is the way I work and I feel fine with it. My complication rate is certainly not worse than that of others, I like working precisely and I take the time for it. I learned this during my residency from two surgeons that I still feel are among the best ones I ever met. I absolutely do have the impression (but no evidence, let alone proof) that even skilled surgeons that work hastily, only to show how good they are, do not have the best results. Of course, in acute situations working quickly (and adequately !) can be necessary, but if such conditions are not there it is no special merit to be a racing surgeon. Speed is not a measure for skill, and there no special value in mentioning it as a sole parameter in articles.
I am a fast surgeon, not because I hurry but because I was taught during my residency to not waste motions (keep fingers in or out of rings of needleholders, but do not put them in and take them out; move my body so my hands are in best position (least awkward); anticipate and be sure the surg techs knows what I will need; use properly positioned mechanical retractors wherever possible to free up assistants and prevent shifting field of hand-held retractors; always ask myself how I can do next similar operation better.
In contrast, one of the other general surgeons in town is on the far side of the bell curve slow. For example, his open inguinal hernias are routinely scheduled for 4 hours; he spent all night one night doing colonoscopy, exploration, gastrostomy and cecostomy on a patient with colonic pseudo-obstruction, and he routinely spends all day (7:30-5) on colon resections, even right colon resections. It appears to me (but I am definitely biased) that his patients stay in hospital longer, he definitely does use a lot more IV hyperal.
I have seen this everywhere I have operated (MN, IL, MO, KS, SD)–a wide range of operative times for same procedures.
In fact, at U of Kansas where I trained, we were exhorted to work quickly by not wasting time, but in same institution, it was said (and it was true) that the Orthopedists could not even finish the skin prep before a spinal would wear off. They got a new Ortho attending who was used to more timely operating, but his cases went just as slow.
Anyhow, it does not seem like a geographic variation.
Duration of an operation is a complex issue that involves skill, anatomical knowledge, philosophy and cultural and social biases.
Skill and knowledge of anatomy, make operation last longer or shorter. I remember watching Ferguson do a mastectomy at U of C. He took about two hours to raise the flaps. But, the flaps were exactly 1 mm thick at the apex, and tapered down evenly to exactly 5 mm at the base. To me, that was an owesome display of skill.
On the other hand, I had the pleasure of assisting Dr. Mattox do a carotid endarterectomy. He showed me that by preparing everything in advance, and not wasting any motions, that endarterectomy can be completed in 18 minutes or less. That too was owesome.
Tradition is also important.
There is a famous anecdote about Cushing’s early days at Hopkins. Halstead was doing a gastrectomy. e begun in the morning, and 4 or 5 hours later, Cushing saw him coming out of the theater. He started yelling for strichnine hypodermic, which was the prime Rx for shock those days, but Halstead calmed him down, explaining that the patient was stable, in spite of the long operation.
For Cushing, the long operation meant that there were complications. To Halstead, that was the normal state of affairs. I wish I was half as good a surgeon as these two were in their time.
I think this is also reflected in the the findings of the CDC regarding the effect of duration on wound infection rate. It is not the length of the operation that makes wound infection rate rise; instead, it is the duration RELATIVE to the usual duration of similar operation by the same surgeon in the same institute. A longer duration than usual means that there were complications and wound infection rate increases.
Philosophy enters into play where one looks for the goals of the operation. More radical operation take longer. If one insists on clearing R2 lymphnodes in a gastrectomy, that takes longer then simply whipping out the stomach.
This example also highlights the issue of temperament. Trauma and vascular surgeons, tend to be fast operators, and they should. Oncological surgeons tend to be more deliberate.
Finally socioeconomic factors play a role. In Israel, the public health system demands a tight operative schedule. At 1:30 pm they won’t anesthetise another elective case. There is a constant pressure to finish the schedule, and fast surgeons are appreciated by their peers, and ancillary staff, because they can finish early and have coffee in the lounge. In the USA, there is no such pressure, or at least I have not encountered one, and operations can proceed at a more leisurely pace.
Just to give some data as a background for the discussion I surveyed our registry to find out the situation in my place. I might add that operation time and blood loss are part of an ongoing project we have to understand the problems about how operations are conducted. These are the operation times for some standard procedures in colorectal surgery.
Procedure N mean op time min-max
Right colectomy 132 2.2 hrs 0.9-4.9 (some
laparoscopic)
Left colectomy 148 2.5 1-8.1 (some
laparoscopic)
Total colectomy for u.c. 52 2.8 1.5-6.7 (some
laparoscopic)
Ant res with coloanal
pouch plus ilostomy 85 3.5 2-6.2
rectal excision 45 4.3 3-8.8
(some laparoscopic)
Laparoscopic resections have taken one hour longer on average.
It is imediately evident that there is a wide spread and one wonders why. We score all our operations for their technical content (difficulty) in seven variables, each scored 0, 1 or 3, representing the analogue scale of 1-50th percentile (score 0), 51-75th percentile (score 1), 76-100th percentile (worst 25%, score 2). It gives maximum score 14 when all the variables are totalled, but scores above 5 are unusual.
An example from ant. res. with coloanal pouch reconstruction:
technical score 0 score 1-2 score 3-4 score 5-14
op. time 3.2 hrs 3.5hrs 3.9 hrs 4.5 hrs
So, operation time goes up as the technical difficulty increases, no surprise.
Blood loss increases geometrically with operation time, roughly dubbling with every hour of the operation. On average the figures are just short of 100ml first hour, 200 ml second hour, 400 ml third hour hour etc. But the variation is wide.
Both operation time and blood loss increases with the magnitude of the operation (magnitude of the dissection) . We rank our operations 1-4 where a partial colectomy is grade 2, ant.res. grade 3, and rectal excision is grade 4.
A linear multiple regression analysis gives this result for 900 intraabdominal colorectal operations including more than the standard operations given above.
Op.time = 0.7 + 0.6 x opgrade (1,2,3 or 4) + 0.1 x technical score (0-14) + 0.0011 x blood loss in mL.
Gender, age, and body mass index are rejected by the regression as not being indepent contributors.
Example: right hemicolectomy without problems: 0.7+0.6×2+0+0.0011x50mL = 2hrs.
Do not attach too much exactness about the figures but look at the factors in the equation. The opgrade is fixed by convention. It could be replaced by operative diagnosis or procedure. We cannot change that. It is the technical score and the blood loss that can be influenced. The technical score is the principal surgeons own score against the background of his experience. The residents might score points where I would score zero. It reflects how well he thought the operation proceeded, detailed in seven variables.
There should probably be a correction factor for surgeon in the equation, but the technical score picks up most of the interindividual variation.
The blood loss is important. We changed our technique and halfed the median blood loss for all standard procedures. The operation time went down significantly. We gained time by being more careful about hemostasis.
There is nothing special about the above but it provides me with figures for what we all think is important, and what the problems are. It all becomes possible to analyse.
I allow myself a few impressions:
It is necessary to be very careful about the technical content. The surgeon must learn to operate with a minimum of movements and skip all unnecessary bits of the operation because each such bit takes time and increases the complexity of the operation. The complexity must decrease because we are human beings and every little bit extra blocks our minds thinking about it being necessary in this case or not. The operation must be made without hokus pokus or it becomes like a child4s play were you are fed bits of information until you do not know how to proceed. Thinking about “it” is the worst time spoiler in an operation.
I have in a previous posting stressed the mental aspects of the conduct of an operation. The surgeon must acquire a high degree of confidence in his work. This must be strong enough to allow the surgeon to continously change the way the surgeon operates. The confidence must allow him to remain confident when the unnecessary bits are deleted. To my mind the best way to achieve this is to operate together with a partner that you respect. The simpler the better is very true if you wish to save time and do a better job.
My senior partner and myself did a total mesorectal excision with colon pouch-anal anastomosis and a diverting loop-ileostomy in a big man in just under two hours last week. I admit it was an operation without problems. Had I had one of the senior residents to assist me (one that can do the operation) the operation would have been at least half an hour longer. Had two of the senior residents done it, it would have been between 1 and 2 hours longer. The message is: how do we install skill and confidence in those we train?
Surgeons are different and operate differently. Each surgeon has his own line of development. The operation time differs 1-2 hours between surgeons for standard operations simply because the way they are. It was beatifully demonstrated in learning curves for laparoscopic colectomies.
There are probably three principal reasons why surgeons are slower: lack of skill and lack of confidence, and a lot of unneccessary things that mainly serves the purpose of being a back-up for the other deficiencies. Suppose you were trained by such a surgeon, you won4t know it unless you study others. It is very likely that you continue the way you were trained. Whole departments follow a similar line. It does not necessarily mean that your results are worse although it is likely. I apologise if someone takes offence by this statement, it only reflects my impression as an acute observer.
I am not much in favour of quick surgery if it means careless surgery. What I am talking about is making confident surgeons making operations simple. It gains time. Surgery is a mental activity and it is a team activity. Moshe4s question about why the operation time is so different in published reports is probably answered by: the surgeons4 conduct of the operation is different. They all do a Whipple but how they do it is very different. The wide spread in operation time serve as a measure of how important the conduct of an operation is. It is a remainder about that it matters how we do it despite we think differently.
Being the third generation of surgeons in my family I was exposed to more stories and legends. Gradpa was a very fast surgeon considering today’s timing. And he worked without diathermy, did two layer anastomoses without stapling technique and closed peritoneum. So how fast he must have been today ? This was only an example, but out of studiyng others’ stories there is a definite trend of slowing pace with every generation. The ” technically skilled ” surgeon is going out in favor of the academic surgeon, and time matters less nowadays. Residents are not send to improve their technical skills. One like Leriche took sewing lessons with the greatest embroidery artist in Paris at the time. It was essential in those days ; it was then a worthy example. Who would do it today ? How much time do we spend in today’s training improving our manual skills ? Pre- and postoperative management take more than the surgical act itself ( and I’m not standing against it ).
French school surgeons are more rapid because of better technique and latin spirit. But what can we do about surgeons raised in the same place going to the same fellowships and operating rapidly or slowly ( is it culture ? is it training ? ). I think it has to do with personal skills.
I mean to resume it like that ( personal view ) :
– Rapid surgery is essential in emergency conditions.
– Elective surgery must be done in reasonable time ( somewhere midscale minus ) considering that very long operation times are sometimes ” excluded ” from publication.
I use to announce the OR staff about the lenght of an operation adding 10% to my expected time as soon as I can evaluate it. I generally ” arrive there in time “. It helps the anesthesiologist to do his part.
I did a lap appy last weekend in 20 minutes which amazed me (and the OR
crew)–the only thing that I could attribute this increased speed to was
my left hand track ball use.
I believe duration of surgery is often related to knowledge of the anatomy, surgeon’s confidence in his own abilities & rapid decision making, proper use & control of assistants’ hands and retractors, and thinking about more complex procedures in advance so that options can be planned & alternative approaches employed depending on the pathology encountered.
I find it astonishing that one can take 4 hours for a hernia and an entire day for a right colon. These are “bread & butter” general surgery cases! Does not this surgeon consider increased infection rate with longer time, increased anesthesia and O.R. costs and the inconvenience to other surgeons & staff of tying up an O.R. for so long?
I definitely feel that the system under which one practices affects the duration of surgical procedures. In Canada, OR time is definitely limited and the role of hospital administrators is to stay within their budgets, keep beds empty and avoid OR overruns. I have worked with both fast and slow surgeons during my training and I think the best surgeons operate fairly rapidly without appearing to do so. The absolute worst scenario is the unskilled surgeon trying to rush. Unfortunately, a public system limits the availability of OR time and encourages overbooking by surgeons and attempts to squeeze in “one more case”.
It’s very difficult speak about opinion. Generaly, its opinions are full of knowledgment and deep. However, I would like tell us my thiks on surgeon’s time.I do not believe in cultural differences in the way of to perform surgery in each country. In all surgical departments there are good,normal and bad surgeons,and also, there are fast,normal and slow surgeons. I know that’s not equal fast that good. But the reality is this. So,I think that each surgeon have a special predeterminism to be fast, normal or slow,in spite of his or her master. When I see a surgeon to drive a car, before to see him operate, I know how he perform surgery. May be fast or slow, with or without care,etc, but he repeat the same way.
It is very difficult to add something after extensive comments. So I’ll add only a few notes. In cases of random selected operations there are four groups of circumstances, that affect time of operation: OR environment, surgeon, patient and fortune or luck. OR environment include: differences in organisation of work, scill of anesthe- siologist, nurse, assistant, quality of instruments, time of the day, etc. Surgeon itself affects the time of operation because of the skill and training difference, temperament, good or bed mood, degree of tiredness. Patients conditions, differences in anatomy, blood coagulation, degree of pathologic processes also can change operation time. And the fortune is difficult to explain but also important factor. Sometimes you try to do operation quickly but all against you – bleeding from every piese of tisuue, unusual anatomy, assistant doesn’t understand what you want, nurce drops instruments, everything looks bat and operation takes ages. And sometimes everything is so good that you can’t believe that operation done so quickly. As the cultural differences I don’t believe this is true – in every country you can find fast and slow surgeons and different organisation of work in department and OR.
Speed is not the issue nor the goal. I am not a slow Surgeon as measured by the computer printouts, _but_ one takes the time needed with minimal ‘wasted’ movements and a good pre-op plan that you are willing to change of course.
I feel that there is an optimum duration for each procedure (with a certain degree of leeway). I’ve personally worked with some really slow surgeons and others who were extremely quick. A professor I worked with once had a thyroid nodule out before I had even finished scrubbing! He was extremely quick and his patients did well. On the other hand, I have also seen a fast surgeon who had such a bad reputation the A&E would avoid admitting cases when his unit was on call.
Personally, I’ve found that most surgery can be completed fairly quickly if you are familiar with the teritory and don’t muck around doing the unnecessary (akin to what someone said about the pancreas) and yet not compromise on technique. The difficulty is finding the balance.
I too agree that timing for surgical procedures is definitely multifactorial. I believe that each one of us can look back at our earlier years and see how we’ve improved from case to case. The more you do a procedure, the more efficient you become in that procedure. This can be different in individual cases as everyone has aluded to .(i.e. fatty, bleeding, previous surgery, etc.).