Hierarchical task analysis for identification of interrelationships between ergonomic, external disruption, and internal disruption in complex laparoscopic procedures



Traditionally, hierarchical task analysis (HTA) in surgery examines observable disruption in a predefined set of tasks as performed, rather than examining the ergonomics requirements, which may predispose surgical teams to act erroneously. This research aims to address this gap in the literature. It develops a HTA protocol taking into consideration surgical team actions, observable external disruption, internal disruption, and ergonomic goals required for safer conducting procedures. Laparoscopic radical prostatectomy (LRP) is selected as a case.


This research involved observations inside operating rooms (ORs) of three large teaching hospitals in Australia and China. Two rounds of observations are conducted: observations for developing HTA, and observations after presenting the developed HTA among surgical teams. The traditional HTA format is expanded to include two additional columns: technical considerations and ergonomics considerations. Two groups are formed from the observed LRPs. LRPs in the first group were conducted with no regard to the specified ergonomic goals and associated ergonomic features, and the second are conducted with the surgical teams attempting to follow specified ergonomic goals and features as prescribed in HTA. Careful attempt is required to select procedures such that the total operative times for both groups are approximately equal (± 5%).


Between March 2016 and November 2017, a total of 29 LRPs were observed, and a HTA developed. The results reveal significant reduction (43%) in the total external disruptive events and approximately 58% reduction in the internal disruptive events in LRPs conducted with HTA requirements.


The developed HTA appears to have some utility, but needs evaluation in larger studies. It can potentially be used as a training aid, and as a checklist for evaluating surgical performance.

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We would like to acknowledge the support of Professor Xiaoying Zhou, Deputy President, and Ms Mingli Yang, Director of International Affair Office at the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China. The authors appreciate the work of Mr Todd Manning, Department of Anatomy and Developmental Biology, Monash University, Australia, for editing the first draft of the manuscript. The authors would like to acknowledge the effort of Mr. Kapil Sethi, Urological Surgical Fellow at the Austin Hospital, Melbourne Australia, for organising several observations.

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Correspondence to Latif Al-Hakim.

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The authors Latif Al-Hakim, Ming Wang, Jiaquan Xiao, Dennis Gyomber, and Shomik Sengupta have no conflicts of interest or financial ties to disclose.

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Al-Hakim, L., Wang, M., Xiao, J. et al. Hierarchical task analysis for identification of interrelationships between ergonomic, external disruption, and internal disruption in complex laparoscopic procedures. Surg Endosc 33, 3673–3687 (2019). https://doi.org/10.1007/s00464-018-06656-z

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  • Disruption
  • Ergonomic requirements
  • Hierarchical task analysis
  • Laparoscopic radical prostatectomy
  • Performance appraisal, training aid