Anesthesia in the News
  • Anesthesia Challenges in Robotic-assisted Surgery

    Since its introduction in 1983, minimally invasive robotic-assisted surgery (RAS) has enabled surgeons to perform certain types of complex procedures with increased precision, flexibility, and control, reaping patient benefits from reduced blood loss and fewer complications to shorter hospital stays and faster recovery compared to conventional surgical techniques.

    Robo caveat

    However, using robots during minimally invasive surgery has fostered new challenges for surgical teams already navigating a unique and multifaceted work environment.  Challenges with RAS range from patient positioning and the often the long duration of the procedure to the complex, highly technical equipment itself.  These challenges may alter the manner in which surgical team members interact, potentially affecting patient safety and quality of perioperative care related to RAS.

    The goal of one study recently published in the AORN Journal was to ascertain the anesthesia aspect of teamwork during RAS which might help identify areas for improvement.

    The researchers, four of the five of whom are nurse anesthetists, cited previous literature both on the linkage between human error and adverse events (Gjeraa et al, 2016), and that a lack of teamwork may be a cause of preventable patient injury and death (Gill et al, 2016) (Manser et al, 2009).

    Importantly, the authors were unable to find any research specifically focusing on teamwork and the role of the anesthesia provider during RAS.

    Frontline feedback

    The exploratory qualitative study cohort was comprised of three anesthesiologists and six nurse anesthetists from a regional university hospital with 880 beds and 31 ORs located in Norway.

    Participants, who were required to be employed full time with some experience in RAS, were individually interviewed using a semi-structured interview guide which yielded an accumulated 150 pages of transcribed content of the interview proceedings.

    Participants were asked questions about their experiences with teamwork in general and during RAS, soliciting both positive and negative experiences and suggestions for improvements.

    Defining terms

    For purposes of this study, the authors defined a team as at least two interdependent individuals with distinct role assignments who interact with one another and make decisions to achieve a common goal or purpose.

    Successful teamwork results from every member having a distinct role on the team, they state, with each team member knowing and carrying out his or her role with skill and creativity.  Further, team members also should be knowledgeable about the responsibilities and activities of the other team members and cognizant of the ways that different members’ personalities affect team dynamics.

    For RAS to be efficient and successful, OR personnel should be capable of working well both independently and together as members of a well-structured team.  However, such teamwork can be difficult to achieve for various reasons.  For instance, the researchers note that one study found that levels of team skills varied among three different disciplines on a surgical team (ie, surgeons, anesthesia professionals, perioperative nurses) (Catchpole, 2018).  They add that one recent review indicated that communication and coordination problems occur frequently during RAS (Catchpole, 2019).

    Teamwork boons and blockers

    By using qualitative content analysis, the authors discovered one main theme: “Teamwork is an important element of patient safety.”  The study concluded that there are valuable nontechnical skills (NTS) that bolster teamwork during RAS, as well as important nontechnical and technical barriers that challenge the formation of teamwork during these procedures.

    In the former category, the anesthesia professionals interviewed believed that knowledge, experience, cooperation, organization, communication, a positive work environment, and inclusion on the team all helped to create effective teamwork during RAS.

    Barriers they cited were communication, exclusion from the team, work environment, cooperation, and technical aspects — all of which posed a challenge to teamwork during RAS.  Interestingly, all participants mentioned the start-up phase as the most challenging phase of RAS.

    Start-up snafu points

    The study defined start up as the phase from the time the patient arrives in the OR to the time the patient has been positioned and docked to the robot and the procedure has begun.

    During the start-up phase, the authors noted, the entire team completes numerous preparatory tasks before the patient is ready for surgery.  Several participants described the start-up phase as “chaotic,” with each team member assigned specific tasks for completion at the same time and as quickly as possible.  Sometimes these tasks collide, and conflicts arise due to a lack of communication and cooperation, thereby causing interruptions and creating an unpleasant atmosphere, the interviews revealed.

    All participants described patient positioning as the most challenging part of the start-up phase, mentioning that, after being positioned and docked to the robot, the patient cannot be moved, making it even more critical to have optimal patient positioning from the outset

    The researchers suggest that positioning the patient should be a shared responsibility among anesthesia professionals, perioperative nurses, and surgeons, as without proper patient positioning, patient outcomes may be compromised (Hsu et al, 2013) (Kaye et al, 2013).

    The feeling of chaos during the start-up phase indicates a need for leadership and coordination, the authors assert.  Some study participants advocated a clear leader in the OR, while others believed that the nature of leadership is more nuanced and that different phases of the procedure require different leaders.

    Countering ‘chaos’

    One solution to the potential confusion, the authors suggest, is the development of a checklist for the start-up phase of RAS that includes everyone involved, with an assigned coordinator in charge

    “This checklist, covering aspects not included in previous checklists, may positively affect communication and cooperation, improve efficiency and workflow, and enhance patient safety.  The team would be able to identify important tasks more easily and provide a predictable series of tasks for all members of the team.”

    Some participants described the presence of an experienced nurse anesthetist, providing help and support during the start-up phase, as reassuring.  Other participants, particularly those with little involvement with RAS, expressed that they “tend to feel like guests in the OR during RAS because of their limited experience.”  Some of them noted that they do not receive enough training in the specifics of RAS.  The authors state that this lack of experience among anesthesia professionals causes inefficiency, interrupts the workflow, and may be a source of irritation and frustration.

    The value of the intangibles

    Some study participants did not mention technical skills as being associated with positive experiences of teamwork during RAS, perhaps because the technical skills required for RAS are the same as for other surgical procedures, the authors postulate.

    While both technical skills and NTS play a role in caring for patients in the OR, nontechnical skills are an essential part of teamwork, they state.  Therefore, more focus on NTS is needed to achieve effective teamwork during RAS.

    The researchers propose that conducting training sessions that emphasize NTS might be a strategy to improve communication and cooperation.  Such team-based training focusing on NTS may also lead to an increased use of NTS among surgeons, they add.  Simulation, too, they note, has proven to be an effective method of training together and improving teamwork.


    To learn more about your anesthesia colleagues’ study, “Myklebust MV, Storheim H, Hartvik M, Dysvik E. Anesthesia Professionals’ Perspectives of Teamwork During Robotic-Assisted Surgery.” AORN J. 2020 Jan;111(1):87-96., click here: