ENT-surgical workflow as an instrument to assess the efficiency of technological developments in medicine

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Abstract

Evaluation of efficiency of technology in operation room was done almost subjectively in past. This does not fulfil the requirement of a reliable data pool. The goals of this study are a prototypic ontology for surgical procedures, a practicable form of workflow collection and the exemplary evaluation of surgical workflows by example of endonasal videoendoscopic sinus surgery (FESS). The study included altogether 38 FESS-procedures (20 patients). Surgical procedures were accomplished by 7 different surgeons with different degrees of training. For description of surgical procedures and resources, we used the standard EN1828/2001. For workflow modelling, we used the Workflow Reference Models (Workflow Management Coalition, WfMC) as a reference. 1029 different positions of the endoscope, summarized to 5 major-positions were documented. The average time in holding one endoscope position was 1.31 min. 27.1 changes of endoscope position were recorded at each side. 32% were caused by cleaning. 29 changes of surgical instruments were found. 48.3% are justified in the single-hand conception FESS. This study offers a discussion basis for development of ontology, recording and analysis of surgical workflows and their practical application. Our analysis proves the need for assistance by guiding the endoscope apart from surgeon's hand. Pre-conception details of a mechatronic system to solve the clinical requirements are based on workflow analysis. Analysis of complex surgical procedures and their modification will be a basis of future conceptions of technology in OR.

Introduction

Technological developments in medicine like neuromonitoring, shaver, laser or new instruments demand high capital investment. For example, according to the Millenium Research Group 2003, the scientific capital investment for surgical navigation systems is approximated to be one billion US dollars worldwide. That is the fact why developments can no longer depend on the “trial and error” method. Evaluation of efficiency of technology in operation room was done almost subjectively in past. This does not fulfil the requirement of a reliable data pool. Intuitive developments increase the risk of non-efficient solutions. Effectivity means a variance comparison [1], [2]. A medicine-technological system is effective if it fulfils its required benefits regardless of economic aspects. Efficiency means to achieve a predefined output (outcome) with a minimal amount of input (resources) or to achieve a maximum amount of output using a predefined input. Also technological developments have to be beneficial for at least one of the following groups: the patient, the surgeon and the OR staff or the economic sponsor. So these technological developments primary interfere with resources in the OR. Detailed examinations of the surgical operational procedure were neglected so far in surgery. This may be explained due to the complex ontology. Already minor surgical procedures like endonasal videoendoscopic sinus surgery provide over 400 possibilities of surgical work steps like surgical strategy, alternative strategy, type of instrument or time of instrument use which cannot be acquired and analysed reasonable without technical help. Surgical workflows allow a comparison of different surgical strategies (gold-standard), a surgical analysis of assistance requirements and above all objective efficiency examinations of the used resources [3], [4], [5], [6]. For the ostensible technological developments in medicine workflows already allow an effect simulation in the conception period [7]. The goals of this study are a prototypic ontology for surgical procedures, a practicable form of workflow collection and the exemplary evaluation of surgical workflows by example of endonasal videoendoscopic sinus surgery (FESS).

Section snippets

Methods

First we defined standards to describe surgical procedures like surgical aim or alternative strategies (ontology). We developed a software for registration of the surgical procedure in conjunction with the used resources (anaesthesia time, used instruments, image sources). We also defined standards concerning goals, resolution (granulation level), validity (evidence level) and the illustration of workflows. We acquired workflow data by evaluating a total of 38 video endoscopic functional sinus

Results

Based on our classification and the developed registration software, we could acquire ENT-surgical workflows. The average operation time of each side of the anterior and posterior ethmoid, the frontal and the maxillary sinus was 25.2 min. Summarizing the endoscope positions with a difference of tip alignment less than 10 mm 5 major-endoscope positions were found:

  • 1.

    the central view to the middle concha and the anterior ethmoid,

  • 2.

    the posterior view to the posterior ethmoid and the sphenoidal sinus,

  • 3.

Conclusion

Our analysis proves the need for assistance by guiding the endoscope apart from surgeon's hand. Endoscope guidance by surgeon results in an ergonomic deficit and a significant additional surgery time. We assume that by bimanual surgery, additional surgery time could be saved. A rigid mechanic endoscopic guidance system like it is used in other cases needs low investment [9]. The summarizing of the endoscope positions would facilitate the positioning. A rigid mechanic endoscopic guidance system

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