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The effect of intraoperative distractions on severe technical events in laparoscopic bariatric surgery

  • 2020 SAGES Oral
  • Published:
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Given the complexity of the operating room (OR), it is unsurprising that surgeons frequently feel distracted while performing operative tasks. However, this relationship is not well studied in live surgeries. The objective of this study is to investigate the relationship between intraoperative distractions and technical events using surgical data.


Roux-en-Y gastric bypass operation data from three tertiary care hospitals in Toronto, Canada were collected prospectively between 2017 and 2019 by a comprehensive operative capture platform (OR Black Box) and analyzed retrospectively. Time-synchronized audiovisual recordings of the OR and laparoscopic videos of the operation were collected, along with clinical data from the electronic health record. Video data was labeled for technical data, non-technical data, and distractions by trained coders. Procedural steps were categorized based on criticality. The relationship between severe technical events (case having 0 or 1 events vs. 2 or more) and the rate of distractions (machine alarms, external communications, people entering/exiting) in critical procedural steps was assessed through logistic regression, adjusting for team factors (surgeons’ technical skills, nurse changeovers).


60 Roux-en-Y cases were analyzed. Average case duration was 83.2 min (SD = 21.97). Distractions occurred 47.6 times/h (SD = 20.3), with most frequent distraction being machine alarms (4.45/10 min, SD = 2.88). For unadjusted analysis, alarms (OR = 1.29, 95% CI 1.05–1.66) and surgeon’s technical skills (OR = 0.65, 95% CI 0.43–0.93) were found to be correlated with severe technical events. After adjusting for team factors, alarms were found to be positively related with the presence of severe technical events (OR = 1.58, 95% CI 1.18–2.33) during high-criticality procedural steps.


This study showed a significant association between intraoperative distractions, in particular machine alarms, and severe technical events during high-criticality procedural steps. Further investigation will assess the temporal relationship between distractions and technical events and assess mitigation strategies to create a safer surgical environment.

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The authors would like to thank Karthik Raj, Amar Chaudhry, Alex Ahn, Stephen Townsend for their technical help, and Dr. Bijan Dastgheib, Dr. Qurrat Tahir, and Dr. Sara Elkabany for their participation in clinical discussions.


The funding for this work was provided by several sources: the Stipend of Suzan Ayas was provided by a Natural Sciences and Engineering Research Council of Canada (NSERC) Discovery Grant (RGPIN-2016-05580) and the University of Toronto Centre for Healthcare Engineering. The Stipend of Dr. Lauren Gordon was provided by a Canadian Institutes of Health Research (CIHR) Frederick Banting and Charles Best Canada Graduate Scholarship Doctoral Award (CGD-D), the John L Provan Fellowship in Surgical Education administered by the University of Toronto, and the University of Toronto Department of Surgery.

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Correspondence to Birsen Donmez.

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Dr. Teodor Grantcharov holds Intellectual Property Ownership of Surgical Safety Technologies, Inc. and is supported by Research Grants from Medtronic Canada, Ethicon Canada, Baxter Canada, Olympus Canada, Takeda Canada, and Intuitive Surgical. Suzan Ayas, Dr. Lauren Gordon, and Dr. Birsen Donmez have no conflicts of interest to disclose.

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Table 6 SEVERE framework [10] illustrating the types of events identified and their corresponding severity rating descriptions


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Ayas, S., Gordon, L., Donmez, B. et al. The effect of intraoperative distractions on severe technical events in laparoscopic bariatric surgery. Surg Endosc 35, 4569–4580 (2021).

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