Is fast or slow surgery more dangerous
Do you believe that surgical speed is associated with surgical quality? Is a speedy surgeon “dangerously fast”? Is a slow surgeon more likely operating safely? Since I was not sure what I should think about this topic, I asked the twitter community.
Interestingly, the vote fell 56% versus 44% in favour of people who believe that fast surgical speed can increase the risk of surgical complications.
I then went to PubMed to check what is available in the peer-reviewed literature on the topic. There were only 5 papers on the topic covering caesarean sections, gastric cancer surgery, bariatric surgery, vascular surgery and one paper covered various surgical specialties. All 5 papers were retrospective.
The most outstanding paper was a recent literature review (Cheng et al, J Surg Res 2018) covering 7 prospective and 59 retrospective studies with a sample size ranging from 49 to 299,359 patients. Most papers assessed the issue in general surgery, urological and colorectal surgery. Specifically, 81% (48/59) of retrospective cohort studies and 71% (5/7) of prospective cohort studies reported that prolonged operative duration was associated with a statistically significant increase in the risk of complications. For obstetrics and gynaecology surgery (4 studies reviewed), the risk of complications ranged from 2.1% to 29.0% (infected lymph cyst, wound infections, surgical site infections, ileus, and renal complications). The association between operative duration and complication subtypes was significant in all studies. The mean operative time was reported by three studies; it ranged from 2.8 to 4.2 h. The meta-analysis of two studies showed an 86% statistically significant increase in the likelihood of experiencing a complication with increased operative time
There was one other paper that was not covered in the literature review because it was a secondary analysis of an observational study (no intervention) and is on the effect of surgical speed in caesarean section (Moroz et al, AJOG 2015). If the baby was delivered in less than 2 minutes from skin incision, the risk of a maternal complication was 66% higher.
There are several reasons why speedy surgery could be related to favourable outcomes. Surely, for some complication types a correlation of surgical duration with outcome is not unexpected. For example, longer operating time is correlated robustly across virtually all studies with an increased risk of surgical site infection. This is likely caused by longer exposure to germs. However, for other complications (cardiac or renal failure) this association is still consistently displayed but its cause is less clear. While it is theoretically possible that intra-operative complications could have prolonged operating time, the literature review paper could adjust for that by focussing on postoperative outcomes.
The literature review paper also discusses that longer operation duration also may cause team fatigue, which may increase the risk of multiple types of adverse events. Good evidence exists that team familiarity reduces surgical operating times (Huckman & Staats, The hidden benefits of keeping teams intact, HBR 2013) and in one of our own papers we demonstrated that familiarity of surgical teams was predictive of surgical outcomes (Obermair et al. The impact of team familiarity on surgical outcomes in gynaecological surgery. J Obstet Gynecol 2020).
In SurgicalPerformance, surgeons can record their perceived team familiarity and compare their hospital-specific scores with their own scores from other hospitals or with scores from colleagues. SurgicalPerformance users can discuss their concerns about low familiarity scores with their operating theatre managers to negotiate a regular team of nurses and techs.
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