To highlight his point, Dr. Bhayani presented a case of a patient who underwent a 9-hour kidney operation in the flank position. When the drapes were removed at the end of the operation, there was skin breakdown and brown urine, which rapidly progressed to muscle breakdown, renal failure and a diagnosis of severe rhabdomyolysis. This patient subsequently underwent multiple fasciotomies/debridements, with a prolonged hospitalization and eventual litigation. A second case presented was of a patient undergoing a 7-hour robotic prostatectomy in the steep trendelenberg position. This patient had undiagnosed glaucoma, and subsequent to the prolonged increased intraocular pressure associated with the extended trendelenberg position, the patient awoke with complete blindness, which also resulted in litigation.
These cases highlight the steep learning curve, specifically when learning robotic surgery, and the devastating outcomes that may result from unnecessarily prolonged operative times. Particularly with the pressure to complete the case robotically, there may be an aversion to opening and completing the case in a timely fashion. As Dr. Bhayani points out, it is necessary to take a step back and assess the outcome of the case in real time. As importantly, it is crucial to have voices in the OR to collaboratively decide on a plan when the case runs longer than it should.
Dr. Bhayani and his team having been pioneers in developing a second “time-out” checklist for lengthy robotic surgeries [1]. The second "time-out" was aimed at reducing peri-operative complications and addressing obstacles presented by lengthy robotic surgeries. After reviewing the literature to identify the most common complications of robotic surgeries with extended operative times, a surgical checklist was developed with the goal of addressing these issues and maximizing patient safety:
Key elements of the checklist were designed to coordinate operative staff in verifying patient safety while addressing the unique concerns within each specialty. A standardized surgical checklist, conducted three to four hours after the start of surgery, may enhance perioperative patient safety and quality of care. At Washington University, Dr. Bhayani has rolled out the second timeout by asking surgeons to adopt it on a voluntary basis. A group of surgeons utilizing the second time-out have expressed positive feedback so far, and his team’s initial experience has demonstrated relatively minimal intrusion to the case time for the second time-out to be performed (as little as a few minutes to complete). As such, Dr. Bhayani is continuing to accrue further feedback and ongoing studies are being performed to evaluate its effectiveness.
Presented By: Sam Bhayani, Washington University School of Medicine, St. Louis, MO
Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, @zklaassen_md ,at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV
References:
1. Song JB, Vemana G, Mobley JM, et al. The second “time-out”: A surgical safety checklist for lengthy robotic surgeries. Patient Safety in Surg 2013;7:19.