Workflow Analysis of Laparoscopic Nissen Fundoplication in Infant Pigs-A Model for Surgical Feedback and Training

Background: Many fields use workflow analysis to assess and improve performance of complex tasks. In pediatric endosurgery, workflow analysis may help optimize operative planning and motor skills by breaking down the procedure into particular phases, evaluating these steps individually, and supplying feedback to the surgeon. Objective: To develop a module of computer-based surgical workflow analysis for laparoscopic Nissen fundoplication (LNF) and to evaluate its applicability in an infant pig model. Methods: LNF was performed in 12 pigs (weight, 7-10 kg) by a single surgeon. Based on synchronized intra-and extracorporal movie recordings, the surgical workflow was segmented into temporal operative phases (preparation, dissection, reconstruction and conclusion). During each stage, all actions were recorded in a virtual timeline using a customized workflow editor. Specific tasks, such as knot-tying, were evaluated in detail. Time necessary to perform these actions was compared throughout the study. Results: While time required for the preparation decreased by more than 70% from 4577 to 1379 seconds, and the dissection phase decreased from 2359 to 399 seconds (pig 1 and 12, respectively), the other two phases remained relatively stable. Mean time to perform the entire suture and a 5-throw knot remained constant as well. Conclusion: Our workflow analysis model allows the quantitative evaluation of dynamic actions related to LNF. This data can be used to define average benchmark criteria for the procedures that comprise this operation. It thereby permits task-oriented refinement of surgical technique as well as monitoring the efficacy of training. Although preoperative preparation time decreased substantially, and dissection became faster, time required for the reconstruction and conclusion phases remained relatively constant for a surgeon with moderate experience. Likewise, knot-tying did not accelerate in this setting.