We currently have surgeons who are trying to establish themselves as experts in performing a certain robotic operation. As an open case, it rarely takes more than about 4-5 hours.
With the robot, it is generally taking around 6 hours as reported in the literature, and morbidity and mortality in expert hands appears to be pretty good.
What is happening in the real world is that surgeons are taking 12 or more hours to perform these operations robotically. I am aware of one death after a 14 hour procedure in another hospital. One case in my own institution took 16 hours, and luckily the patient did well. Of course this sort of data never gets reported publicly.
I am trying to develop a policy on prolonged robotic/laparoscopic surgery. My surgeons say it needs to be evidence-based and are worried it may disenfranchise some of them. One does not want to ruffle feathers, but in my mind, 16 hours represents nothing but surgeon ego taking precedence over patient safety.
Creating an evidence based document is almost impossible as there is only circumstantial and anecdotal evidence. By circumstantial, I mean the knowledge such as the effects of CO2 in prolonged laparoscopy although it has never been scientifically correlated with patient mortality.
You may have heard of the death of a patient in India where during a live laparoscopy demonstration, the visiting Japanese surgeon did not yield to recommendations from the audience that he convert to open surgery. When should a line in the sand be drawn for prolonged robotic/laparoscopic surgery and conversion to open surgery be undertaken?
I had heard about the case that occurred in India. It was a laparoscopic liver resection. I blogged about it on Physician’s Weekly.
I was a chairman of surgery at a community hospital in 1990 when laparoscopic cholecystectomy began in the US. We had the same problems you describe. People were taking hours and hours to do cases. Some felt that there was a stigma attached to the conversion of a case to open, and opening was associated with the word "failure."
Fortunately I had a good group of surgeons working with me. We decided that conversion to open was no longer a case that needed to be discussed at M&M. Instead, the surgeon was to be commended for recognizing that the case was not going to be safely done within a reasonable length of time via the laparoscope. We started out by saying if it was clear that no progress was being made by 2 hours into the case, it should be converted to open.
After a year or so, we all came to the conclusion that 1 hour of no progress was enough, and we converted cases at that time. After 20+ years of doing lap choles, I still used 1 hour as my cutoff although I have aborted laparoscopic cases within 5 minutes on occasion. As the song goes, “You've got to know when to hold 'em, know when to fold 'em.”
I think the biggest problem is that each surgeon must be intellectually honest and admit that the case is going nowhere. This can be overcome if everyone gets on board and doesn't refer to a case that is converted as a failure.
There is no evidence. You and your staff need to decide what the threshold for converting is in your situation. Perhaps 6 hours is the magic number.
My readers may have some suggestions too.