SpringerLink
Log in

Non-technical skills in minimally invasive surgery teams: a systematic review

  • Review
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Root cause analyses show that up to 70 % of adverse events are caused by human error. Strong non-technical skills (NTS) can prevent or reduce these errors, considerable numbers of which occur in the operating theatre. Minimally invasive surgery (MIS) requires manipulation of more complex equipment than open procedures, likely requiring a different set of NTS for each kind of team. The aims of this study were to identify the MIS teams’ key NTS and investigate the effect of training and assessment of NTS on MIS teams.

Methods

The databases of PubMed, Cochrane Library, Embase, PsycINFO, and Scopus were systematically searched according to Preferred Reporting Item for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles containing outcome measures related to MIS teams’ key NTS, training, or assessment of NTS were included.

Results

The search yielded 1984 articles, 11 of which were included. All were observational studies without blinding, and they differed in aims, types of evaluation, and outcomes. Only two studies evaluated patient outcomes other than operative time, and overall, the studies’ quality of evidence was low. Different communication types were encountered in MIS compared to open surgery, mainly due to equipment- and patient-related challenges. Fixed teams improved teamwork and safety levels, while deficient planning and poor teamwork were found to obstruct workflow and increase errors. Training NTS mitigates these issues and improves staff attitudes towards NTS.

Conclusions

MIS teams’ NTS are important for workflow and prevention of errors and can be enhanced by working in fixed teams. In the technological complex sphere of MIS, communication revolves around equipment- and patient-related topics, much more so than in open surgery. In all, only a few heterogeneous-design studies have examined this. In the future, the focus should shift to systematically identifying key NTS and develo** effective, evidence-based team training programmes in MIS.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price includes VAT (Thailand)

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Vincent C, Neale G, Woloshynowych M (2001) Adverse events in British hospitals: preliminary retrospective record review. BMJ 322:517–519

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA (2008) The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 17:216–223

    Article  PubMed  PubMed Central  Google Scholar 

  3. Gawande AA, Zinner MJ, Studdert DM, Brennan TA (2003) Analysis of errors reported by surgeons at three teaching hospitals. Surgery 133:614–621

    Article  PubMed  Google Scholar 

  4. Joint Commission on Accreditation of Health Care Organizations Sentinel Event Data Root Causes by Event Type 2004—2Q 2014—Root_Causes_by_Event_Type_2004-2Q_2014.pdf. http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2Q_2014.pdf. Accessed 5 Feb 2015

  5. Østergaard D, Dieckmann P, Lippert A (2011) Simulation and CRM. Best Pract Res Clin Anaesthesiol 25:239–249

    Article  PubMed  Google Scholar 

  6. Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ, Gawande AA (2007) Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 204:533–540

    Article  PubMed  Google Scholar 

  7. Calland JF, Guerlain S, Adams RB, Tribble CG, Foley E, Chekan EG (2002) A systems approach to surgical safety. Surg Endosc 16:1005–1014; discussion 1015

  8. Pucher PH, Brunt LM, Fanelli RD, Asbun HJ, Aggarwal R (2015) SAGES expert Delphi consensus: critical factors for safe surgical practice in laparoscopic cholecystectomy. Surg Endosc 29:3074–3085

    Article  PubMed  Google Scholar 

  9. Flin RH, O’Connor P, Crichton M (2008) Safety at the sharp end: a guide to non-technical skills. Ashgate, Burlington

    Google Scholar 

  10. Yule S, Flin R, Maran N, Rowley D, Youngson G, Paterson-Brown S (2008) Surgeons’ non-technical skills in the operating room: reliability testing of the NOTSS behavior rating system. World J Surg 32:548–556

    Article  PubMed  Google Scholar 

  11. Siu J, Maran N, Paterson-Brown S (2014) Observation of behavioural markers of non-technical skills in the operating room and their relationship to intra-operative incidents. Surg J R Coll Surg Edinb Irel. doi:10.1016/j.surge.2014.06.005

    Google Scholar 

  12. Schiøler T, Lipczak H, Pedersen BL, Mogensen TS, Bech KB, Stockmarr A, Svenning AR, Frølich A, Danish Adverse Event Study (2001) Incidence of adverse events in hospitals. A retrospective study of medical records. Ugeskr Laeger 163:5370–5378

    PubMed  Google Scholar 

  13. Young-Xu Y, Neily J, Mills PD, Carney BT, West P, Berger DH, Mazzia LM, Paull DE, Bagian JP (2011) Association between implementation of a medical team training program and surgical morbidity. Arch Surg Chic Ill 1960 146:1368–1373

    Google Scholar 

  14. Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, Mazzia LM, Paull DE, Bagian JP (2010) Association between implementation of a medical team training program and surgical mortality. JAMA 304:1693–1700

    Article  CAS  PubMed  Google Scholar 

  15. McCulloch P, Rathbone J, Catchpole K (2011) Interventions to improve teamwork and communications among healthcare staff. Br J Surg 98:469–479

    Article  CAS  PubMed  Google Scholar 

  16. Gordon M, Darbyshire D, Baker P (2012) Non-technical skills training to enhance patient safety: a systematic review. Med Educ 46:1042–1054

    Article  PubMed  Google Scholar 

  17. Dedy NJ, Bonrath EM, Zevin B, Grantcharov TP (2013) Teaching nontechnical skills in surgical residency: a systematic review of current approaches and outcomes. Surgery 154:1000–1008

    Article  PubMed  Google Scholar 

  18. Tan SB, Pena G, Altree M, Maddern GJ (2014) Multidisciplinary team simulation for the operating theatre: a review of the literature. ANZ J Surg 84:515–522

    Article  PubMed  Google Scholar 

  19. Cumin D, Boyd MJ, Webster CS, Weller JM (2013) A systematic review of simulation for multidisciplinary team training in operating rooms. Simul Healthc J Soc Simul Healthc 8:171–179

    Article  Google Scholar 

  20. Gjeraa K, Møller TP, Østergaard D (2014) Efficacy of simulation-based trauma team training of non-technical skills. A systematic review. Acta Anaesthesiol Scand 58:775–787

    Article  CAS  PubMed  Google Scholar 

  21. Soot SJ, Eshraghi N, Farahmand M, Sheppard BC, Deveney CW (1999) Transition from open to laparoscopic fundoplication: The learning curve. Arch Surg 134:278–281

    Article  CAS  PubMed  Google Scholar 

  22. Hanna GB, Cresswell AB (1960) Cuschieri A (2002) Shadow depth cues and endoscopic task performance. Arch Surg Chic Ill 137:1166–1169

    Article  Google Scholar 

  23. Zheng B, Fung E, Fu B, Panton NM, Swanström LL (2015) Surgical team composition differs between laparoscopic and open procedures. Surg Endosc 29:2260–2265

    Article  PubMed  Google Scholar 

  24. de Rooij T, Lu MZ, Steen MW, Gerhards MF, Dijkgraaf MG, Busch OR, Lips DJ, Festen S, Besselink MG, Dutch Pancreatic Cancer Group (2016) Minimally Invasive Versus Open Pancreatoduodenectomy: Systematic Review and Meta-analysis of Comparative Cohort and Registry Studies. Ann Surg. doi:10.1097/SLA.0000000000001660

    Google Scholar 

  25. Veldkamp R, Kuhry E, Hop WCJ, Jeekel J, Kazemier G, Bonjer HJ, Haglind E, Påhlman L, Cuesta MA, Msika S, Morino M, Lacy AM, COlon cancer Laparoscopic or Open Resection Study Group (COLOR) (2005) Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 6:477–484

    Article  PubMed  Google Scholar 

  26. Graafland M, Schraagen JMC, Boermeester MA, Bemelman WA, Schijven MP (2015) Training situational awareness to reduce surgical errors in the operating room. Br J Surg 102:16–23

    Article  CAS  PubMed  Google Scholar 

  27. Arora S, Sevdalis N, Nestel D, Woloshynowych M, Darzi A, Kneebone R (2010) The impact of stress on surgical performance: a systematic review of the literature. Surgery 147(318–330):e1–e6

    Google Scholar 

  28. Silvennoinen M, Mecklin J-P, Saariluoma P, Antikainen T (2009) Expertise and skill in minimally invasive surgery. Scand J Surg 98:209–213

    CAS  PubMed  Google Scholar 

  29. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700

    Article  PubMed  PubMed Central  Google Scholar 

  30. Kirkpatrick DL (2005) Evaluating training programs: the four levels, 3rd edn. Berrett-Koehler, San Francisco

    Google Scholar 

  31. Ghaderi I, Manji F, Park YS, Juul D, Ott M, Harris I, Farrell TM (2015) Technical skills assessment toolbox: a review using the unitary framework of validity. Ann Surg 261:251–262

    Article  PubMed  Google Scholar 

  32. Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, Vist GE, Falck-Ytter Y, Meerpohl J, Norris S, Guyatt GH (2011) GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol 64:401–406

    Article  PubMed  Google Scholar 

  33. Guyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, Alonso-Coello P, Montori V, Akl EA, Djulbegovic B, Falck-Ytter Y, Norris SL, Williams JW, Atkins D, Meerpohl J, Schünemann HJ (2011) GRADE guidelines: 4. Rating the quality of evidence-study limitations (risk of bias). J Clin Epidemiol 64:407–415

    Article  PubMed  Google Scholar 

  34. Paige JT, Kozmenko V, Yang T, Paragi Gururaja R, Hilton CW, Cohn I, Chauvin SW (2009) High-fidelity, simulation-based, interdisciplinary operating room team training at the point of care. Surgery 145:138–146

    Article  PubMed  Google Scholar 

  35. Al-Hakim L (2011) The impact of preventable disruption on the operative time for minimally invasive surgery. Surg Endosc 25:3385–3392

    Article  PubMed  Google Scholar 

  36. Catchpole K, Mishra A, Handa A, McCulloch P (2008) Teamwork and error in the operating room: analysis of skills and roles. Ann Surg 247:699–706

    Article  CAS  PubMed  Google Scholar 

  37. Guerlain S, Adams RB, Turrentine FB, Shin T, Guo H, Collins SR, Calland JF (2005) Assessing team performance in the operating room: development and use of a “black-box” recorder and other tools for the intraoperative environment. J Am Coll Surg 200:29–37

    Article  PubMed  Google Scholar 

  38. McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K (2009) The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care 18:109–115

    Article  CAS  PubMed  Google Scholar 

  39. Mishra A, Catchpole K, Dale T, McCulloch P (2008) The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy. Surg Endosc 22:68–73

    Article  CAS  PubMed  Google Scholar 

  40. Mishra A, Catchpole K, McCulloch P (2009) The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre. Qual Saf Health Care 18:104–108

    Article  CAS  PubMed  Google Scholar 

  41. Paige JT, Kozmenko V, Yang T, Gururaja RP, Hilton CW, Cohn I, Chauvin SW (2009) Attitudinal changes resulting from repetitive training of operating room personnel using of high-fidelity simulation at the point of care. Am Surg 75:584–590; discussion 590–591

  42. Sevdalis N, Wong HWL, Arora S, Nagpal K, Healey A, Hanna GB, Vincent CA (2012) Quantitative analysis of intraoperative communication in open and laparoscopic surgery. Surg Endosc 26:2931–2938

    Article  PubMed  Google Scholar 

  43. Stepaniak PS, Heij C, Buise MP, Mannaerts GHH, Smulders JF, Nienhuijs SW (2012) Bariatric surgery with operating room teams that stayed fixed during the day: a multicenter study analyzing the effects on patient outcomes, teamwork and safety climate, and procedure duration. Anesth Analg 115:1384–1392

    Article  PubMed  Google Scholar 

  44. Zheng B, Martinec DV, Cassera MA, Swanström LL (2008) A quantitative study of disruption in the operating room during laparoscopic antireflux surgery. Surg Endosc 22:2171–2177

    Article  PubMed  Google Scholar 

  45. Sørensen SMD, Savran MM, Konge L, Bjerrum F (2015) Three-dimensional versus two-dimensional vision in laparoscopy: a systematic review. Surg Endosc. doi:10.1007/s00464-015-4189-7

    PubMed  Google Scholar 

  46. Mentis HM, Chellali A, Manser K, Cao CGL, Schwaitzberg SD (2015) A systematic review of the effect of distraction on surgeon performance: directions for operating room policy and surgical training. Surg Endosc. doi:10.1007/s00464-015-4443-z

    Google Scholar 

  47. Alarcon A, Berguer R (1996) A comparison of operating room crowding between open and laparoscopic operations. Surg Endosc 10:916–919

    Article  CAS  PubMed  Google Scholar 

  48. Stavroulis A, Cutner A, Liao L-M (2013) Staff perceptions of the effects of an integrated laparoscopic theatre environment on teamwork. Gynecol Surg 10:177–180

    Article  Google Scholar 

  49. Rodrigues SP, Kuile MT, Dankelman J, Jansen FW (2012) Patient safety risk factors in minimally invasive surgery: a validation study. Gynecol Surg 9:265–270

    Article  PubMed  Google Scholar 

  50. Buljac-Samardzic M, Dekker-van Doorn CM, van Wijngaarden JDH, van Wijk KP (2010) Interventions to improve team effectiveness: a systematic review. Health Policy Amst Neth 94:183–195

    Article  Google Scholar 

  51. Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, Erwin PJ, Hamstra SJ (2011) Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA 306:978–988

    CAS  PubMed  Google Scholar 

  52. Hull L, Arora S, Symons NRA, Jalil R, Darzi A, Vincent C, Sevdalis N, Delphi Expert Consensus Panel (2013) Training faculty in nontechnical skill assessment: national guidelines on program requirements. Ann Surg 258:370–375

    Article  PubMed  Google Scholar 

  53. Brunckhorst O, Shahid S, Aydin A, McIlhenny C, Khan S, Raza SJ, Sahai A, Brewin J, Bello F, Kneebone R, Khan MS, Dasgupta P, Ahmed K (2015) Simulation-based ureteroscopy skills training curriculum with integration of technical and non-technical skills: a randomised controlled trial. Surg Endosc 29:2728–2735

    Article  PubMed  Google Scholar 

  54. Thomas EJ, Sexton JB, Helmreich RL (2003) Discrepant attitudes about teamwork among critical care nurses and physicians. Crit Care Med 31:956–959

    Article  PubMed  Google Scholar 

  55. Bhangu A, Bhangu S, Stevenson J, Bowley DM (2013) Lessons for surgeons in the final moments of Air France Flight 447. World J Surg 37:1185–1192

    Article  PubMed  Google Scholar 

  56. Healey AN, Undre S, Vincent CA (2004) Develo** observational measures of performance in surgical teams. Qual Saf Health Care 13(Suppl 1):i33–i40

    Article  PubMed  PubMed Central  Google Scholar 

  57. Undre S, Sevdalis N, Healey AN, Darzi SA, Vincent CA (2006) Teamwork in the operating theatre: cohesion or confusion? J Eval Clin Pract 12:182–189

    Article  PubMed  Google Scholar 

  58. Hull L, Sevdalis N (2015) Advances in teaching and assessing nontechnical skills. Surg Clin North Am 95:869–884

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

Funding was provided by The Danish Cancer Society (Grant number: R100-A7166).

Author information

Authors and Affiliations

  1. Copenhagen Academy for Medical Education and Simulation (CAMES), Capital Region of Denmark, Rigshospitalet, Section 5404, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark

    Kirsten Gjeraa, Lars Konge & Doris Østergaard

  2. Surgical Department, Nordsjællands Hospital, Hillerød, Denmark

    Lene Spanager

  3. Department of Cardiothoracic Surgery, University Hospital of Copenhagen, Rigshospitalet, Copenhagen Ø, Denmark

    René H. Petersen

  4. Copenhagen University, Copenhagen, Denmark

    Kirsten Gjeraa, Lars Konge & Doris Østergaard

Authors
  1. Kirsten Gjeraa
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lene Spanager
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lars Konge
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. René H. Petersen
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Doris Østergaard
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kirsten Gjeraa.

Ethics declarations

Disclosures

Dr. René Horsleben Petersen is a compensated speaker for Covidien, Ethicon, Medela, and Takeda. Drs. Kirsten Gjeraa, Lene Spanager, Lars Konge, and Doris Østergaard have no conflicts of interest or financial ties to disclose.

Appendix 1: Search terms and strategy

Appendix 1: Search terms and strategy

#1

Non-technical

#2

Non technical

#3

Nontechnical

#4

Non-technical skill

#5

Non-technical skills

#6

Non-technical performance

#7

Teamwork

#8

Team intervention

#8

Team intervention

#9

Team interventions

#10

Team training

#11

Team development

#12

Team innovation

#13

Team program

#14

Team programs

#15

Team education

#16

Team improvement

#17

Team improvements

#18

Team improve

#19

Team management

#20

Crew resource management

#21

Crisis resource management

#22

Human factor

#23

Human factors

#24

Behaviour

#25

Behavior

#26

Behaviours

#27

Behaviors

#28

Error*

#29

Safety

#30

Risk assessment

#31

Impact prevent*

#32

Incident

#33

Adverse events

#34

Adverse event

#35

#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22 or #23 or #24 or #25 or #26 or #27 or #28 or #29 or #30 or #31 or #32 or #33 or #34

#36

Laparoscopy

#37

Laparoscopic

#38

Mediastinoscopy

#39

Mediastinoscopic

#40

Thoracoscopy

#41

Thoracoscopic

#42

Video-assisted surgery

#43

Video-assisted surgery

#44

Surgical endoscopy

#45

Minimal invasive surgery

#46

Minimal invasive surgical

#47

#36 or #37 or #38 or #39 or #40 or #41 or #43 or #44 or #45 or #46

#48

Team

#49

Teams

#50

#48 or #49

#51

#35 and #47 and #50

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gjeraa, K., Spanager, L., Konge, L. et al. Non-technical skills in minimally invasive surgery teams: a systematic review. Surg Endosc 30, 5185–5199 (2016). https://doi.org/10.1007/s00464-016-4890-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-016-4890-1

Keywords

Search

Navigation