• Ken Catchpole, Colby Perkins, Catherine Bresee, M Jonathon Solnik, Benjamin Sherman, John Fritch, Bruno Gross, Samantha Jagannathan, Niv Hakami-Majd, Raymund Avenido, and Jennifer T Anger.
• Department of Surgery, Cedars-Sinai Medical Center, 825 N. San Vicente Blvd., Los Angeles, CA, 90069, USA. Ken.Catchpole@cshs.org.
• Surg Endosc. 2016 Sep 1; 30 (9): 3749-61.

BackgroundExpense, efficiency of use, learning curves, workflow integration and an increased prevalence of serious incidents can all be barriers to adoption. We explored an observational approach and initial diagnostics to enhance total system performance in robotic surgery.MethodsEighty-nine robotic surgical cases were observed in multiple operating rooms using two different surgical robots (the S and Si), across several specialties (Urology, Gynecology, and Cardiac Surgery). The main measures were operative duration and rate of flow disruptions-described as 'deviations from the natural progression of an operation thereby potentially compromising safety or efficiency.' Contextual parameters collected were surgeon experience level and training, type of surgery, the model of robot and patient factors. Observations were conducted across four operative phases (operating room pre-incision; robot docking; main surgical intervention; post-console).ResultsA mean of 9.62 flow disruptions per hour (95 % CI 8.78-10.46) were predominantly caused by coordination, communication, equipment and training problems. Operative duration and flow disruption rate varied with surgeon experience (p = 0.039; p < 0.001, respectively), training cases (p = 0.012; p = 0.007) and surgical type (both p < 0.001). Flow disruption rates in some phases were also sensitive to the robot model and patient characteristics.ConclusionsFlow disruption rate is sensitive to system context and generates improvement diagnostics. Complex surgical robotic equipment increases opportunities for technological failures, increases communication requirements for the whole team, and can reduce the ability to maintain vision in the operative field. These data suggest specific opportunities to reduce the training costs and the learning curve.

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