Identifying Workflow Disruptions in Robotic-Assisted Bariatric Surgery: Elucidating Challenges Experienced by Surgical Teams

Obesity is a significant health concern, with bariatric surgery being an effective treatment. While laparoscopic surgery is common, robotic-assisted bariatric surgery (RBS) offers potential benefits but introduces technological complexities. This study uses a human factors engineering (HFE) approach to examine RBS workflow, specifically focusing on flow disruptions (FDs)—deviations from the natural workflow that may compromise safety or efficiency. The prevalence of obesity in the USA increased significantly between 1999 and 2018. Bariatric surgery, primarily performed laparoscopically, has shown effectiveness, but RBS adoption has been slow compared to other surgical specialties. While RBS offers potential advantages such as more articulated wrist movements, improving upon limitations of laparoscopic surgery like limited abdominal space and thicker abdominal walls, it comes with higher costs and new OR challenges. These challenges include communication barriers due to physical separation between surgeons and their team, restricted work environments, and the need for new training protocols. HFE provides a useful framework for understanding these challenges, allowing for improvements in workflow, safety, and efficiency. Prior research shows a link between increased FDs and higher perceived workload, distractions, and stress among OR team members, highlighting the need for workflow improvement in RBS. This study aims to utilize an HFE approach by identifying FDs during RBS to understand the systemic challenges of robotic integration in bariatric surgery, guiding interventions for minimizing delays and operative time.

Existing literature highlights the increasing prevalence of obesity and the effectiveness of bariatric surgery. While laparoscopic approaches dominate, the adoption of robotic-assisted surgery (RAS) in bariatric surgery has been slower than in other surgical specialties. Studies report comparable outcomes between RBS and laparoscopic bariatric surgery (LBS) regarding complications like anastomotic leaks and length of stay. However, RBS is considerably more expensive. The literature also points to the unique challenges of RBS, including communication barriers, space constraints in the operating room (OR), and the need for specialized training. Previous human factors studies in other surgical specialties have successfully used the identification and classification of flow disruptions (FDs) to improve workflow and safety. These studies indicate that increased FDs correlate with increased workload and stress among surgical team members. However, the impact of RAS work system configurations on surgical teams remains unexplored in the context of RBS.

This direct observational study, conducted between October 2019 and March 2022 across three hospital sites, observed 29 RBS procedures. The study received IRB approval, and informed consent was deemed exempt as only de-identified data were collected. Observers received 25 hours of training, including literature review, video observation of general surgery practice, FD identification and classification practice, and shadowing. Data collection involved real-time recording of FDs during each RBS procedure. De-identified patient data (age, sex, BMI, ASA classification) were obtained from patient charts. A macro-enabled Microsoft Excel tool was used to record time-stamped FDs, describe them, and classify them into nine categories (coordination, communication, environment, equipment, external factors, other, patient factors, surgical task considerations, training) and assign severity scores (0, 1, 2). The total FDs were used to calculate averages, standard deviations, and confidence intervals for all cases. FD rates per hour were determined for each surgical phase. A sub-analysis was performed on the most frequent FD category (coordination) using an open card sorting method to identify contributing factors. Two trained researchers reviewed 100 FD narratives to develop sub-categories, achieving substantial inter-rater reliability (k=0.75).

A total of 1733 FDs were observed across the 29 RBS procedures, averaging 59.76 FDs per procedure (CI = ± 7.29). The average FD rate was 25.05 per hour (CI = ± 2.77). The highest FD rates occurred during phase 2 (insufflation to robot docking; M = 29.37, CI = ± 4.01) and phase 5 (patient closure to transport; M = 30.00, CI = ± 6.03). Coordination FDs were most frequent overall (M = 9.63, CI = ± 1.72), followed by environment (M = 5.23, CI = ± 1.02) and communication (M = 3.56, CI = ± 0.74). The highest coordination FD rates were observed during phase 2 (robot docking; M = 14.28, CI = ± 3.11). The sub-analysis of coordination FDs revealed that unavailable staff/instruments (22.59%), equipment readjustments (14.26%), handling supplies (10.40%), assistance/support needs (9.51%), and inadvertent/incorrect actions (8.02%) were the most frequent contributors.

The study revealed a high FD rate (one every 2.4 min) in RBS, exceeding rates observed in other surgical specialties. Coordination issues were the most prevalent, followed by environmental and communication challenges. The high FD rate during phase 5 (patient transfer and transport) is attributed to environmental and coordination issues, likely exacerbated by space constraints and the need for assistance with obese patients. Similarly, the high FD rate during phase 2 (robot docking) reflects challenges in preparing the OR, retrieving supplies, and navigating space constraints. The sub-analysis of coordination FDs highlighted inefficiencies in planning and supply management as key contributors. These findings suggest that targeted interventions are needed to improve team coordination, resource availability, and OR preparation.

This study demonstrates the significant workflow disruptions in RBS, particularly during patient transfer/transport and robot docking. Coordination challenges, stemming from insufficient planning and resource management, are the most significant contributors. Implementing systems-focused interventions, such as improved preoperative briefings, gamified training programs (like "RAS Olympics"), and effective communication strategies, can potentially mitigate these disruptions, leading to improved efficiency and patient safety in RBS.

The study had a limited sample size (29 procedures) and included only five types of RBS procedures. Observations were conducted at multiple sites with varying OR sizes and staff configurations, potentially influencing the results. The observational nature of the study raises the possibility of the Hawthorne effect. While FD rates, not totals, were used to account for procedure-specific challenges and phase duration variations, the lack of an LBS control group limits the comparison of workflow differences between RBS and LBS. Furthermore, staff experience was not measured.