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Anticipation, teamwork and cognitive load: chasing efficiency during robot-assisted surgery
  1. Kevin Sexton1,
  2. Amanda Johnson1,
  3. Amanda Gotsch1,
  4. Ahmed A Hussein1,2,
  5. Lora Cavuoto3,
  6. Khurshid A Guru1
  1. 1 Department of Urology, ATLAS Program, Roswell Park Cancer Institute, Buffalo, New York, USA
  2. 2 Urology, Cairo University, Cairo, Egypt
  3. 3 Industrial and Systems Engineering, University at Buffalo - The State University of New York, Buffalo, New York, USA
  1. Correspondence to Dr Khurshid A Guru, Department of Urology, ATLAS Program, Roswell Park Cancer Institute, Buffalo, New York, USA; Khurshid.Guru{at}


Introduction Robot-assisted surgery (RAS) has changed the traditional operating room (OR), occupying more space with equipment and isolating console surgeons away from the patients and their team. We aimed to evaluate how anticipation of surgical steps and familiarity between team members impacted efficiency.

Methods We analysed recordings (video and audio) of 12 robot-assisted radical prostatectomies. Any requests between surgeon and the team members were documented and classified by personnel, equipment type, mode of communication, level of inconvenience in fulfilling the request and anticipation. Surgical team members completed questionnaires assessing team familiarity and cognitive load (National Aeronautics and Space Administration – Task Load Index). Predictors of team efficiency were assessed using Pearson correlation and stepwise linear regression.

Results 1330 requests were documented, of which 413 (31%) were anticipated. Anticipation correlated negatively with operative time, resulting in overall 8% reduction of OR time. Team familiarity negatively correlated with inconveniences. Anticipation ratio, per cent of requests that were non-verbal and total request duration were significantly correlated with the console surgeons’ cognitive load (r=0.77, p=0.006; r=0.63, p=0.04; and r=0.70, p=0.02, respectively).

Conclusions Anticipation and active engagement by the surgical team resulted in shorter operative time, and higher familiarity scores were associated with fewer inconveniences. Less anticipation and non-verbal requests were also associated with lower cognitive load for the console surgeon. Training efforts to increase anticipation and team familiarity can improve team efficiency during RAS.

  • Audit and feedback
  • Communication
  • Human factors
  • Performance measures
  • Teamwork

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  • Contributors None.

  • Funding This research was supported in part by funding from the National Cancer Institute of the National Institutes of Health under award number: R25CA181003, and Roswell Park Alliance Foundation.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval Roswell Park Cancer Institute IRB.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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