Surgical Endoscopy

, Volume 32, Issue 12, pp 4763–4771 | Cite as

High-resolution standardization reduces delay due to workflow disruptions in laparoscopic cholecystectomy

  • Marco von Strauss und TorneyEmail author
  • Sohelia Aghlmandi
  • Jasmin Zeindler
  • Debora Nowakowski
  • Christian A. Nebiker
  • Christoph Kettelhack
  • Rachel Rosenthal
  • Raoul A. Droeser
  • Savas D. Soysal
  • Henry Hoffmann
  • Robert Mechera



Optimal resource utilization in high-cost environments like operating theatres is fundamental in today’s cost constrained health care systems. Interruptions of the surgical workflow, i.e. microcomplications (MC), lead to prolonged procedure times and higher costs and can be indicative of surgical mistakes. Reducing MC can improve operating room efficiency and prevent intraoperative complications. We, therefore, aimed to evaluate the impact of a high-resolution standardized laparoscopic cholecystectomy protocol (HRSL) on operative time and intraoperative interruptions in a teaching hospital.


HRSL consisted of a detailed stepwise protocol for the procedure, supported by a teaching video, both to be reviewed as mandatory preparation by each team member before surgery. Audio–video records of laparoscopic cholecystectomies were reviewed regarding type, frequency and duration of MC before and after implementation of HRSL.


Thirty-nine (20 control and 19 HRSL) audio–video records of laparoscopic cholecystectomies with a total duration of 51.36 h (28.92 pre 22.44 post) were reviewed. The majority of operations (86%) were performed by teams who had completed less than 10 procedures together previously. Communication-related interruptions and instrument changes accounted for the majority of MC. Median frequency and duration of MC were 95 events/h and 15.6 min/h, respectively, of surgery pre-intervention. With HRSL this was reduced to 76 events/h and 10.6 min/h of operating. In multivariable analysis, HRSL was an independent predictor for shorter delay and lower frequency of MC [percentage decrease 27% (95% CI 18–35%), resp. 30% (95% CI 19–40%)]. Procedure-related risk factors for the longer delay due to MC in multivariable analysis were less experience of the surgeon and intraoperative adhesiolysis.


HRSL is effective in reducing delays due to MC in a teaching institution with limited team experience. These findings should be tested in larger potentially cluster-randomized controlled trials.

The trial has been registered with NCT03329859.


Microcomplications Workflow Disruption Intraoperative delay Duration of surgery Costs Laparoscopy 



The authors want to thank Charles Rudin for his technical support and advice in audio–video recording and preparing the audio–video records for analysis and Alistair Geraghty for his careful and critical review of the manuscript as native speaker.

Compliance with ethical standards


Rachel Rosenthal is an employee of F. Hoffmann-La Roche Ltd. since 01 May 2014. The present study has no connection to her employment by the company. Rachel Rosenthal continues to be affiliated with the University of Basel. Marco von Strauss und Torney, Sohelia Aghlmandi, Jasmin Zeindler, Debora Senn, Christian Nebiker, Christoph Kettelhack, Raoul Droeser, Savas Soysal, Henry Hoffmann and Robert Mechera have no conflict of interest or financial ties to disclose.

Supplementary material

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Supplemental digital content (SDC 1) (DOC 26 KB)
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464_2018_6224_MOESM4_ESM.docx (17 kb)
Supplemental digital content (SDC 4) (DOCX 17 KB)

Supplemental digital content (SDC 5) (MP4 26955 KB)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Marco von Strauss und Torney
    • 1
    Email author
  • Sohelia Aghlmandi
    • 2
  • Jasmin Zeindler
    • 1
  • Debora Nowakowski
    • 1
  • Christian A. Nebiker
    • 1
    • 3
  • Christoph Kettelhack
    • 1
  • Rachel Rosenthal
    • 1
  • Raoul A. Droeser
    • 1
  • Savas D. Soysal
    • 1
  • Henry Hoffmann
    • 1
  • Robert Mechera
    • 1
  1. 1.Department of General and Visceral SurgeryUniversity Hospital BaselBaselSwitzerland
  2. 2.Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital BaselUniversity of BaselBaselSwitzerland
  3. 3.Department of SurgeryCantonal Hospital of AarauAarauSwitzerland

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