A multifactorial evaluation of objective performance indicators and video analysis in the context of case complexity and clinical outcomes in robotic-assisted cholecystectomy

The increased digitization in robotic surgical procedures today enables surgeons to quantify their movements through data captured directly from the robotic system. These calculations, called objective performance indicators (OPIs), offer unprecedented detail into surgical performance. In this study, we link case- and surgical step-specific OPIs to case complexity, surgical experience and console utilization, and post-operative clinical complications across 87 robotic cholecystectomy (RC) cases.

Videos of RCs performed by a principal surgeon with and without fellows were segmented into eight surgical steps and linked to patients' clinical data. Data for OPI calculations were extracted from an Intuitive Data Recorder and the da Vinci ® robotic system. RC cases were each assigned a Nassar and Parkland Grading score and categorized as standard or complex. OPIs were compared across complexity groups, console attributions, and post-surgical complication severities to determine objective relationships across variables.

Across cases, differences in camera control and head positioning metrics of the principal surgeon were observed when comparing standard and complex cases. Further, OPI differences across the principal surgeon and the fellow(s) were observed in standard cases and include differences in arm swapping, camera control, and clutching behaviors. Monopolar coagulation energy usage differences were also observed. Select surgical step duration differences were observed across complexities and console attributions, and additional surgical task analyses determine the adhesion removal and liver bed hemostasis steps to be the most impactful steps for case complexity and post-surgical complications, respectively.

This is the first study to establish the association between OPIs, case complexities, and clinical complications in RC. We identified OPI differences in intra-operative behaviors and post-surgical complications dependent on surgeon expertise and case complexity, opening the door for more standardized assessments of teaching cases, surgical behaviors and case complexities.