Unfortunately, operating times are one of the components of surgical planning that cannot be estimated with a great degree of precision. A previous European research study observing 1000 common gynaecological procedures revealed that although most laparoscopies could be completed within 75 minutes, their durations varied widely, ranging from 10 to 400 minutes. This lack of predictability makes it difficult to accurately organise the fixed session times around which operations are scheduled. For women with endometriosis, the issue is further compounded by the fact that history and examination findings (which are usually used to guide estimations of operating time) are often quite vague, and poorly reflect the state of disease that is actually present. Therefore, when doctors perform laparoscopic (keyhole) surgeries to diagnose or remove endometriosis, it is not uncommon for the surgical findings to be quite different to what was expected from their previous examinations! This can be problematic for both the operating team – who may not have the resources necessary to adequately manage the encountered disease– and also for the patient, whose surgery may progress for much longer than originally anticipated, or who may possibly have to return for further surgical interventions.
These issues form the basis behind the research project that is currently being undertaken by a team of doctors and medical students at Alana and the University of NSW respectively. The aim of the project is to investigate how accurately medical professionals are able to predict operating times based on their patients’ history and physical examination findings. The focus population for this study consists of women with suspected endometriosis who have been scheduled for a diagnostic or therapeutic laparoscopy.
The project involves three stages:
STAGE 1: Following clinical appointments, the examiner makes a note of their patients’ estimated disease stage and estimated operating time, based on clinical and physical examination findings.
STAGE 2: As standard preoperative practice, the examinations and estimations are then repeated just prior to surgery, once the patient has been anaesthetised. The second assessment allows researchers to investigate whether factors such as pain and patient discomfort affect physical examination findings and subsequent estimates.
STAGE 3: Ultimately, the exact operating time and actual disease locations are recorded during surgery and compared to the original predictions.
Another question that is being explored through this project is whether the examiner’s experience has any impact on the findings. Are consultants any better than trainee gynaecologists at estimating operating times and disease stages? And how do medical students compare to their senior practitioners? To investigate these issues, the project was designed so that clinicians of varying experience levels performed examinations in both stages of the patient assessments.
Since the project commenced in March 2014, what have the results and findings indicated? Is there any truth in the suggestion that a more experienced doctor is better at estimating operating times? And just how good (or bad!) are medical professionals at estimating how long a procedure is going to take?
Using results from the first 95 cases, the preliminary findings of this study suggested that estimations for operating time more-or-less lay within the vicinity of actual operating times, and that doctors could therefore predict operating times with a certain degree of accuracy.
Subcategorizing the results by the examiners’ different experience levels further revealed that novice examiners have a rather poor ability to predict operating times, with many of their estimations falling quite far from actual observations – and this is entirely logical considering their relative inexperience. Consultants fared much better, with estimations and actual times having similar values. Again, this is explainable by the fact that these physicians are much more practiced at inferring disease states from physical examination findings, and subsequently can give more accurate estimations of surgical duration. At this stage, further analysis is still needed to clarify whether these results are in fact statistically significant, and to further explore the other study aims.
And what is the application of this research when applied to real-world settings? Hopefully the findings of the study will allow conclusions to be drawn about the utility of physical examinations in predicting operating times, and also identify the examination environment that is likely to result in the most accurate estimations. Ultimately, this would ensure that appropriately experienced clinicians consult with hospital administrations to facilitate the optimal use of resources. More importantly, it would also allow clinicians to provide their patients with a much more detailed understanding of their upcoming surgeries and give them a better idea of what to expect of their hospital stays.
The above study (Pelvic examination findings for women with endometriosis: A comparison of clinical and surgical examination) is currently underway at UNSW under the direction of Associate Professor Jason Abbott and the GRACE research team. Study sites are the Royal Hospital for Women and the Prince of Wales Private Hospital.