ORIGINAL ARTICLE

ANZJSurg.com

Optimizing the operating theatre environment

ans_5526

917..924

Shing W. Wong, Richard Smith and Phil Crowe

Department of Surgery, University of New South Wales, Prince of Wales Hospital, Randwick, New South Wales, Australia

Key words
human engineering, operating rooms, operative,
outcome assessment, surgical procedures, task
performance and analysis.
Correspondence
Dr Shing Wai Wong, Department of Surgery, Prince of
Wales Hospital, Barker Street, Randwick 2031,
Australia. Email: [email protected]
S. W. Wong FRACS, MS; R. Smith MB BS;
P. J. Crowe PhD, FRACS.

Abstract
The operating theatre is a complex place. There are many potential factors which can
interfere with surgery and predispose to errors. Optimizing the operating theatre
environment can enhance surgeon performance, which can ultimately improve patient
outcomes. These factors include the physical environment (such as noise and light),
human factors (such as ergonomics), and surgeon-related factors (such as fatigue and
stress). As individual factors, they may not affect surgical outcome but in combination,
they may exert a significant influence. The evidence for some of these working
environment factors are examined individually. Optimizing the operating environment
may have a potentially more significant impact on overall surgical outcome than
improving individual surgical skill.

Accepted for publication 15 June 2010.

doi: 10.1111/j.1445-2197.2010.05526.x

Introduction
In 1962, DM Douglas commented that the surgeon looks upon the
theatre suite as his workshop in much the same way as the scholar
his library, the scientist his laboratory, or the craftsman his bench.1
He proposed that optimizing teamwork, the working environment,
and lighting as important requirements for the design of an operating
theatre from a surgeons perspective.
Surgical outcomes do not just depend on patient factors and
surgeon technical skills. External human factors are also important
and they include ergonomics, team coordination and leadership,
organizational culture, and quality of decision-making.2 Rather than
analysing the contribution of individual factors, a systems approach
to achieving better surgical outcomes has been advocated. Better
outcomes are likely if human error is diminished and surgical safety
is maximized. A systems approach to safety associated with surgical
operations would involve studying all aspects of the system including the working environment.
Reason proposed two methods in analysing human error: the
person approach or the system approach.3 The system approach
assumes that humans are fallible and that errors are expected. Countermeasures aim to change the working conditions because the
human conditions cannot be changed. The Swiss cheese model of
system accidents describes alignment of all the holes in each defensive layer (each cheese slice) leading to adverse outcomes. The holes
in the defences arise from active failures and latent conditions.
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ANZ Journal of Surgery 2010 Royal Australasian College of Surgeons

Within the operating room, the latent conditions which can be identified and modified can help prevent an adverse event.
The environment which surgeons work in has an impact on
clinical decision-making during surgery.4 These work environment
factors are not beyond the control of surgeons. Optimizing the operating theatre environment can enhance surgeon performance, which
can ultimately improve patient outcomes. These factors include the
physical environment (such as noise and light), human factors (such
as ergonomics), and surgeon-related factors (such as fatigue and
stress). As individual factors, they may not affect surgical outcome,
but in combination, they may exert a significant influence. Many of
these factors have not been studied in a real operating theatre environment but have been examined in other work or simulated environments. Nonetheless, these studies can provide us with important
insight into how these factors influence performance. The aim of
this paper was to review the evidence for some of these working
environment factors.

Lighting
Optimal lighting is required for good vision. Important characteristics of good illumination include strong light, intense area of illumination in the centre, good focus, parallel beams, shadowless, easy
manoeuvrability, shielding to prevent glare, and heat reduction (with
heat-filtering glass).1,5,6 The overhead lights are the most commonly

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Wong et al.

used source of lighting in the operating room. The surgeon or the

assistants head may obstruct the light from the light source to the
operation field in deep cavities. One of the disadvantages is that
regular adjustment of the overhead operating light may be required
and this can increase the risk of contamination and infection. The use
of the main and satellite overhead lights together may improve the
field of illumination but different intensities and reflections may
compromise vision.
Use of a headlight has advantages of flexibility, control by the
surgeon, and vision into deep and narrow spaces.1 Disadvantages of
using a headlight include an awkward posture (resulting in neck
strain) and limitation of the mobility and visibility of the operating
team.7 Flexible fibre-optic lights attached to retracting instruments
can be used to overcome some of these drawbacks. The light is
stronger and better focused when fibre-optic light is used in laparoscopic, endoscopic and arthroscopic work. There are drawbacks.
Vision can be impaired when the end of the scope is covered by
condensation, blood or fluid. The light fibre-optic fibres can be
damaged with regular use. One study demonstrated that over 20% of
light projected from available light leads had darkened sections
(with diminished or absent light transmission).8 There is also a
danger of burns when the power of the light source is turned up.9
There are other ways that light can help the surgeon. The use of
lighted ureteric stents can aid its identification at laparoscopy.10 The
use of different wavelength light can also be beneficial to surgeons.
Blue-enriched white light in the operating theatre has been used by
laparoscopic surgeons to reduce the strain on their eyes from the
video monitors. Eye accommodation focuses on wavelengths in the
middle of the spectrum, with longer (towards red) wavelengths in
virtual focus behind the retina and shorter (towards blue) wavelengths in front of the retina. Less eye accommodation is required
to focus short wavelengths on the retina.11 In a study of 94 office
workers, blue-enriched white light (compared with white light)
improved subjective alertness, mood, performance, evening fatigue,
concentration and eye discomfort.12 Other studies have also shown
an association between increased psychomotor vigilance and
reduced sleepiness with exposure to short wavelength light compared with polychromatic light.13,14
Colonoscopic narrow band imaging (NBI) uses short wavelength
(blue) endoscopic light to highlight mucosal patterns and microvascular details. NBI can differentiate between colonic neoplastic and
non-neoplastic lesions with a sensitivity of 92% and a specificity of
86%.15 Infrared light has been shown to help improve differentiation
of the cystic duct and artery, identification of the ureter, and assessment of bowel perfusion by inexperienced laparoscopic surgeons in
an animal study.16

articles examining the impact of stress on surgical performance

found the key stressors to be laparoscopic surgery, bleeding, distractions, time pressure, procedural complexity and equipment problems.19 In this review, the authors found surgical inexperience and
poor coping skills to be associated with greater stress levels and
poorer technical performance.
Medical staff often downplay the effects of stress.17,20,21 There
is emphasis on leadership and self-confidence in the surgical community and stress is often perceived as a sign of failure.22 A survey
of 167 consultant surgeons from 10 hospitals indicated that 82%
believed that they can leave personal problems behind when working.20 Seventy-six percent of surgeons believed that their decisionmaking ability was as good in emergency situations as in routine
situations. This has not been well studied. One study demonstrated a
higher incidence of errors during simulated laparoscopic surgery
under the condition of mental stress with a simple mathematical
task.23
Surgeons may acquire attributes and skills that facilitate performance under pressure. These skills relate to preparation, experience,
personal emotional control, environmental control, focusing on the
big picture, maintaining and restoring order, and maintaining confidence and composure.21 Negative stress coping strategies used
by novice surgeons were shown to correlate with poor technical
performances.24 These negative strategies were escape, rumination,
resignation, self-blame, avoidance and need for social support.
One study found effective coping strategies to be significantly
related to surgical performance during simulated carotid endarterectomy surgery.25 The authors assessment of surgical coping skills
was based on six variables: preventive coping (plan and check to
avoid stressors), anticipatory coping (reduce inevitable stressors),
proactive coping (enhance personal resources), intraoperative
control of self, intraoperative control of the situation, and control of
the overall operative situation. Surgeons stress levels were assessed
by the validated State-Trait-Anxiety-Inventory score, surgical assistant rating, heart rate and variability, and salivary cortisol levels.
Experience was the strongest predictor of performance. Overall,
high coping skills and low stress levels both enhanced surgical
performance. However, coping skills were not related to both the
stress responses and experience. The authors suggested that these
surgical coping strategies should be taught because they are not
automatically acquired with clinical experience. Interestingly, low
stress levels in inexperienced surgeons worsened performance,
possibly related to lack of insight and overconfidence.

Stress and coping

Important considerations for gowns and gloves include the potentially conflicting characteristics of protection and comfort. The need
for a gown to be liquid repellent and to protect the wearer is a
priority. Woven cotton (also known as muslin) is an acceptable
barrier when dry but loses its barrier capabilities when wet.26 One
study indicated that four of five non-woven fabrics from disposable
gowns were effective barriers against the transmission of bacteria in
a laboratory setting, but all three woven fabric from reusable gowns
allowed some transmission of bacteria.27 Laundering has also been

Stress can facilitate performance by enhancing alertness, concentration, focus and efficiency of action as long as the stress level does not
exceed coping skills. High levels of stress can impair technical skills
and non-technical skills such as judgment, decision-making and
communication.17 An observational study of 55 surgical operations
found technical, patient and equipment problems to be the most
stressful factors in the operating room.18 A systemic review of 22

Gowns and gloves

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ANZ Journal of Surgery 2010 Royal Australasian College of Surgeons

Optimizing the operating theatre

shown to reduce the ability of the fabric of reusable gowns to prevent

the transmission of bacteria in an in vitro setting.28
Whilst much attention has been paid to the investigation of which
gowns offer better protection to surgeon and patient from contamination, little research has focussed on which gowns are more
comfortable. One study showed that reusable gowns had a blood
contamination rate of 90% compared with 11% for single layer
disposable gowns and 3% for reinforced disposable gowns.29 In this
study, the majority of surgeons felt comfortable and safe in the
disposable gowns, compared with the minority of surgeons in the
reusable gowns. A simulated operating theatre study revealed
the overall comfort of reusable and disposable gowns to be equivalent despite the higher thermal insulation of the latter.30 The amount
of sweating was less with disposable gowns compared with reusable
gowns. Reusable cotton gowns were subjectively hotter than disposable non-woven gowns.
The benefits of double gloving in preventing perforation have
been well documented by a Cochrane review.31 Furthermore, they
showed that triple gloving, knitted outer gloves, and glove liners also
reduce perforations, and that indicator systems (with a different
colour glove inside to indicate outer perforation) result in significantly more perforations being detected during surgery. However,
this was not related to a significant reduction in surgical site infections. The drawback of double gloving includes constriction of the
hands and fingers which can lead to discomfort and paraesthesiae.
The use of a larger inner glove may mitigate this tightness of fit.
The evidence for the influence of double gloving on performance
is conflicting. One study found no significant difference in 2-point
discrimination and number of knots tied in 60 s, with both single and
double gloves.32 Another study found no significant impairment in
2-point discrimination or manual dexterity (assessed by pegboard
assembly) with double gloves compared with single or no gloves in
53 subjects.33 However, this study was funded by the glove manufacturers. Conversely, other studies have found double gloving to
significantly impair surgeons perception of comfort, sensitivity and
dexterity.34,35 Supplemental hand protection systems such as puncture resistant gloves, finger guards and glove liners protect against
needle puncture but significantly reduces cutaneous sensibility.36
In this study, the authors also found that cutaneous sensibility was
similar between the normal latex gloves and the thicker latex gloves.

Noise
Noise is a potential problem for concentration and communication in
operating theatres. Studies have found highest noise levels during
orthopaedic and neurosurgical procedures.37,38 The loudest noises
tended to be recorded during the preparation period: a dropped steel
bowl measured 108 decibels (dB); gas escaping a pneumatic wall
outlet measured 98 dB; and raising trolley sides measured 85 dB.39
Normal speech between staff measured 60 dB. During surgery,
the background noise tended to be much less, with the sucker and
ventilator the main sources of continuous noise. Sound levels only
exceeded the moderate range (6080 dB) for 1% of the time.
However, it was these uncontrollable, unpredictable noises which
produce a startle response, and can interfere with the performance of
complex tasks.
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For speech noise to be clearly understood, it needs to be 10 dB

above the ambient noise level. A relaxed-to-raised vocal effort is up
to 66 dB and therefore ambient noise in the operating room should
be kept to below 56 dB. The mean noise level of an operating theatre
in one study was above this recommendation at 58 dB.40 One laboratory study indicated that speech understanding was impacted negatively by background dental office noise but not by the presence of
a surgical mask.41
The effect of noise on surgical performance may depend on the
complexity of the task and the experience of the surgeon. In two
separate papers, the same group found contradictory results on the
effect of background noise at 8085 dB on laparoscopic performance in a laboratory setting.23,42 One study found background
noise impaired dexterity and significantly increased the incidence
of errors while the other study found no impact of noise on the
performance of a complex laparoscopic task. Time, number of
movements, total path length, global score, accuracy and knot
quality did not change with the condition of loud background noise.
The former study involved a simpler laparoscopic transfer task and
the latter study involved a more complex task of laparoscopic suturing. The authors postulated that the higher levels of concentration
required with the more difficult task may allow surgeons to block
out the noise.
Another laboratory-based study found that pre-recorded noise
from an actual operating room (5090 dB) worsened robot-assisted
laparoscopic performance by medical students.43 These authors
found a greater detrimental influence of noise on more difficult
tasks. The level of noise and the type of noise (random versus
continuous) are other noise variables which need to be considered
when analysing their effect on surgical performance.

Music
It has been postulated that appropriate use of music in the operating
theatre can reduce stress and improve staff performance.44 Music has
been shown to reduce surgeon stress and enhance surgical performance in a laboratory setting.45 Autonomic cardiovascular reactivity
was significantly less and speed and accuracy of task performance
was significantly better with background music. Surgeon-selected
music resulted in significantly better results than experimenterselected music, which was better than no music. However, the 50
male surgeons involved in the study were volunteers who normally
listen to music during their surgery. This selection bias could partially explain the favourable results of the study. In contrast, laparoscopic surgical performance was unaffected by background classical
music in a study of 12 surgeons of varying experience.42 A randomized controlled trial of 45 novice laparoscopic surgeons found
a detrimental effect of activating music on surgical performance
accompanied by a significantly increased autonomic response (heart
rate).46 The effect of music on performance may be related to the
experience of the surgeon.
Familiar music has been shown to significantly increase the heart
rate and increase detections in a vigilance task, as well as decrease
vigilance decrement over time.47 The type of music did not seem to
have a significant effect. In another study, subjects spatial task
performances were noted to be enhanced by a Mozart sonata

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compared with listening to relaxation tape and silent conditions.48

The spatial IQ scores were 119, 111 and 110 for the three conditions,
respectively.
The influence of music on patient comfort and anaesthetist performance should also be taken into account when considering
whether music should be played in the operating theatre. Studies
have indicated a potential anxiolytic, analgesic and sedative benefit
of music.4953 A survey of 144 anaesthetists found that one quarter
felt that music reduced their vigilance and impaired their communication with other staff.54 A study of 12 anaesthetic trainees found no
significant difference in psychomotor performance (testing numeric
vigilance, tracking and reaction time) under four conditions (classical music, self-chosen music, white noise and silence).55 The 24
non-anaesthetist participants in another study were able to judge
trends in simulated patient monitoring more accurately while listening to music.56 Despite this finding, participants reported a preference to work in silence.

Interruptions
A high frequency of distractions and interruptions occur in the operating theatre and they can affect surgeon concentration. A Disruptions in Surgery Index has been proposed by one group.57 They
classified surgical disruptions into seven domains: individuals skill,
performance and personality; operating room environment; communication; coordination and situational awareness; patient-related
disruptions; team cohesion; and organizational disruptions. The
overall disruptions rate was reported to be 25% by surgeons, 37% by
anaesthetists, and 42% by nurses.
Distractions from case-irrelevant communications have been
studied.58 Visitors to the operating room provided most of these
distractions. Those addressed to the surgeons were less distracting to
the theatre team than those directed to the nurse or anaesthetist. The
inconsequential background conversations (small talk) may help
reduce stress and tensions of the operating team but may also be
more distracting than quieter, non discernable noise for a surgical
team.39

Theatre temperature
The temperature of an operating theatre is often determined by
the anaesthetist, with due consideration to the needs of the patient,
balanced against his/her own comfort as well as that of the entire
theatre staff. Maintaining normothermia for the patient is of paramount importance for many reasons. Hypothermia is defined as core
temperature below 36 degrees, and is commonly caused in surgery
by exposure to the cold operating room environment, evaporation
of skin sterilizing solutions and impairment of thermoregulation
by anaesthesia.59 Prospective randomized trials have demonstrated
a relationship between hypothermia and increased intraoperative
blood loss, cardiac events and surgical wound infections.60,61
Methods of directly heating the patient; such as forced air warming
systems, heated mattresses and warmed intravenous fluid infusion;
have been shown to prevent hypothermia and improve surgical
outcomes.60,6264

Wong et al.

Theatre temperature is another factor to consider. Some anaesthetists like to turn up the ambient operating room temperature to help
achieve normothermia. This may reduce surgeon comfort levels and
impact on their performance. Whilst it is crucial to set the temperature that best suits the patient, one must also consider the theatre
staff. A recent survey of medical students in Britain found that 12%
of respondents had suffered a near or actual syncopal episode in
theatre; of these, 79% reported hot temperature as a contributing
factor.65 One study of call centre operators found a significant reduction in performance when the temperature was increased from
22.5 to 24.5C.66 Moderate heat stress has also been shown to effect
mental performance by lowering levels of arousal.67
Surgeons prefer an ambient temperature of 1921C and a relative
humidity of 4555%.1,68 To counter for the operating light, a temperature of 18 has been recommended. This was 2.5 lower than
the preferred average of other staff. It was likely a coincidence, the
authors suggested, that the average recorded temperature usually
controlled by the anaesthetist was much closer to their preferred
temperature of 21.5! Cooling vests based on those worn by firemen
and adapted to the surgical environment have been trialled in a
non-clinical setting.69 The preliminary tests found an increase in the
comfort of the surgeon, with measurable benefits in terms of lower
skin temperature and sweat rates.

Posture
Fatigue during surgery can be reduced with better posture. Poor
posture has been shown to impair psychomotor performance.70,71
Discomfort and higher postural shift rate have been shown to have an
adverse effect on the error rate. Open surgical procedures usually
require prolonged standing with occasional awkward body positions. Studies have indicated that general surgeons experience substantial stress to their shoulders, neck and back with their postures
during surgery.72,73 Compared with ENT surgeons, general surgeons
have their backs in bent or/and twisted positions more often, stood
on one leg more often, and sat down less often. Laparoscopic surgery
can result in more postural fatigue than open surgery because it
is accompanied by a more upright posture, as well as less body
movement and weight shifting.74
It has been suggested that adopting a sitting position during part of
the operation may reduce torso fatigue during extended periods of
light manipulative work. However, a study looking at the kinematics
of motion performed in sitting and standing positions reported comparable asymmetry in lumbar lateral flexion and thoracic movement.75 Pelvic asymmetry contributes to musculoskeletal pain by
altering the body dynamics with compensation by spinal movement.
These compensatory trunk movements were not corrected by levelling the pelvis while sitting.
One of the problems with sitting during operations is the lack of
leg space under the operating table. This is associated with a forward
leaning posture, which is a significant risk factor for back pain.
Working while seated has advantages of improved precision and
stability, less total body energy consumption and allowing free
movements of the leg. In a simulated setting of poor leg space, the
trunk posture during standing, supported-standing (riding on a high
saddle chair) and sitting were examined in a Danish study.76 The
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Optimizing the operating theatre

authors found the saddle chair position to be associated with a more

intermediate lumbar spine position less kyphotic than sitting and
less lordotic than standing. The cervical spine was also less flexed
than with standing. However, the arms are raised more forward.
Elevation of the arms to above 45 has been shown to increase the
risk of shoulder and neck pain. The authors recommended alternating between the standing and the supported-standing positions to
avoid any prolonged specific posture.
The working height of the operating table has different impact on
individual muscle load. The static muscular load on the trapezius
muscle has been shown to be above recommended threshold levels
in the standing position when the table was over 5 cm above the
elbow level.76 In the absence of forearm support, the authors recommended the working level to be adjusted to less than 5 cm above
elbow level. The use of armrests in simulated laparoscopic surgery
has been shown to reduce error rates and discomfort significantly.77

Regular theatre staff

The assistance of regular experienced nursing scrub staff and assistant should reduce stress levels and result in better co-ordination for
the procedure. The benefits of an experienced or dedicated team
have been shown. Ideally, the surgeon has to say little and the
instruments flow from the sisters hand to the surgeons without
orders.1 One observational study found that experienced scrub
nurses spent shorter amount of the operation time watching surgery
but performed more anticipatory movements when compared with
intermediate skill nurses.78 Another study reported decreased operating times and reduced conversion rates for laparoscopic cholecystectomy operations with a dedicated trained nursing team.79 This
study was a retrospective study and the operations were performed
in two separate hospitals. The benefit may relate to the system as a
whole rather than just because of a dedicated team.
Non-technical skills of the operating theatre staff are as important
as technical skills in achieving safe and efficient practice. These
non-technical skills include communication, situation awareness,
decision-making, leadership, stress and fatigue management, and
critique.80 Poor communication between team members has been
recognized as a contributing factor for some adverse events. Another
factor which impedes good communication in the operating theatre
is the hierarchical structure.81 Encouraging a non-threatening environment where theatre staff members can speak up has the potential
to improve the operating theatre efficiency and to reduce error.
Stable theatre nurse teams have been shown to enable advanced
planning and promote safety.82 Data collected from interviewing
operating room nurses found factors which potentially lead to errors
in teamwork included constant turnover of teams, overtime work
(which hindered concentration and confidence) and individual emotional distress. Another study found a higher complication rate in a
cataract theatre when there was unplanned leave and replacement of
regular staff by temporary staff.83 However, the authors found no
relationship between the experience of the scrub nurse and complication rates. They attributed the higher complication rate to stress
related to the individual being moved unexpectantly or to the
changed dynamics of the team. The study was limited by being a
retrospective case-control study. Inevitably, team members may
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921

change unexpectedly but stress associated with changed team

dynamics can be reduced by ensuring that all members of the surgical team are at least introduced to one another, as should now
happen with the surgical timeout checklist.
The presence of trainees, either as the operating surgeon or assistant surgeon will also have an impact on the surgical procedures.
A regular experienced trainee can improve the flow of surgery by
anticipating the habitual requirements and movements of the operating surgeon. Studies have shown the presence of trainees during
major operations do not compromise a good outcome, even if they
are the primary surgeon as long as they are supervised.84,85 Trainee
participation enhances their surgical training. On the other hand,
trainee surgeons take longer to perform operations and this may
increase stress levels by the need to complete a surgical list within
an allotted time period. One study found a significant relationship
between the incidence of operative errors and time pressure.23 This
has been identified as a factor which negatively imparts on the
trainees educational experience in the operating room and is likely
to affect his/her surgical performance. A recent study has also shown
that the relationship of the trainee with the consultant surgeon is a
major factor affecting the learning climate of the operating room.86
An interesting finding from a multi-centre trial found that the
duration of surgery for a total hip replacement was significantly
reduced (by 28 min) when the assistant was a surgeons assistant
rather than a trainee.87 Presumably, the operation is more efficient
because the experienced assistant can anticipate the requirements
and operative steps of the surgeon. A robotic assistant is the other
extreme. It offers the advantages of more efficiency (by remembering the exact preferences of the surgeon), less potential tension with
the assistant, more precision and less tremor, better ergonomics, no
fatigability and less retraction forces.8890 The disadvantages include
one less pair of eyes, no dynamic movements and less adaptability.

Fatigue
Human performance have been shown to be impaired by shift work,
circadian rhythm disturbances and fatigue from prolonged work
hours.91,92 Studies have shown that fatigue impairs human performance in a laboratory setting, worsens psychomotor performance
and emotions, and perhaps clinical performance.93,94 However, many
of these studies had methodological flaws and failed to control for
circadian effects.
Surgeons may be at increased risk of making errors when
sleep deprived. One matched retrospective cohort study reported
no significantly increased morbidity with procedures performed the
day after surgeons worked overnight (between midnight and 6.00
hours).95 However, there was an increased morbidity for surgery
performed the day after surgeons worked overnight if sleep opportunities were less than 6 h (6.2% versus 3.4%). Studies examining
the effect of fatigue on simulated laparoscopic task performance
have demonstrated conflicting results, probably related to methodological flaws.96
A meta-analysis showed mood to be more affected by sleep
deprivation than cognitive or motor performance (in that order).97
Other studies examining the effect of fatigue on overall surgical
proficiency have also showed cognitive performance to be more

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impaired than psychomotor skills.98,99 In the post-call condition,

surgeons made 25% fewer cognitive errors than residents but psychomotor skills were equally affected in both groups. These studies
suggest that there should be a greater emphasis in preventing cognitive errors during times of fatigue.

Time of surgery
Shift work disrupts the circadian rhythm and may affect other physiological systems. Studies have shown a decline in mental performance and decision-making during the hours of midnight and 6.00
hours.94,100 Alertness and performance have a rhythmicity with a
maximum in the late afternoon and a minimum around 5.00 hours.
Tasks related to gross motor performance such as strength are better
performed in the evening than the morning and finer motor coordination tasks are better performed in the morning.101 The morning
superiority of the latter tasks has been attributed to a lower circadian
arousal level and less influence of fatigue. The risk of airline pilot
error was increased by almost 50% during the period of the early
morning (24.00 to 6.00 hours) in one study.102 This was attributed to
attention problems and fatigue. Anaesthetic studies have reported a
higher rate of adverse effects for procedures starting in the afternoon
or night.103,104
Surgical studies have not reported this association. There was no
relationship between the timing and outcome of elective coronary
artery bypass graft surgery.105 Perioperative risk was not affected by
surgical start time, day of the week or months when new residents
started. In this study, only elective cases were studied and most were
performed during daylight hours and therefore the effect of the
circadian rhythm were not well analysed. Another retrospective
study also found no relationship between surgical complications and
the time of day for cadaveric kidney transplants.106
Prolonged surgical workload and reduced mental energy may
influence surgical performance during different times of the day. The
time of day which laparoscopic-assisted vaginal hysterectomy was
performed did not influence surgical outcomes in a retrospective
study.107 Paradoxically, the authors found a shorter mean operating
time when cases started in the afternoon compared with first
morning cases. This was attributed to improved proficiency with
practice during the day.

Conclusions
The operating theatre is a complex system. Most operations are
performed efficiently and safely despite the potential for interference
and errors from different sources. Optimizing the operating environment to make the surgeon more comfortable will improve safety
and quality. Certain environmental factors can be controlled. Some
stressors such as noise, outside influences and interruptions can be
reduced by altering operating room practices. Maintaining the same
operating team, more thoughtful scheduling/planning of cases and
better preparation with a good nights rest are some of the methods
that can be used to improve outcomes. The surgeon should also
consider the needs of the patient, anaesthetist and other theatre staff
with the variables of temperature and music. More emphasis and
consideration should be placed on posture and other ergonomic

Wong et al.

factors. The teaching of non-technical skills such as stress management and crisis training would prepare surgeons for the complex
demands of the operating environment. Trainees can receive training
and feedback in a safe environment of a simulated operating theatre.
Surgeons should consider examining their own surgical environment
and then attempt to identify factors that they can control. By enhancing these factors, not only may surgical outcomes be improved but
also satisfaction with the surgical workplace. As surgeons, we have
a responsibility to our patients to optimize the environment in which
they will be operated in.

References
1. Douglas DM. Operating-theatre design. Lancet 1962; 2: 1639.
2. Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW. Systems
approaches to surgical quality and safety. Ann. Surg. 2004; 239: 475
82.
3. Reason J. Human errors: models and management. Br. Med. J. 2000;
320: 76870.
4. Francis DMA. Surgical decision making. ANZ J. Surg. 2009; 79: 886
91.
5. Dawson-Edwards P. Auxiliary overhead spot-light. Lancet 1957; 270:
5256.
6. Browne D. A headlight for general surgery. Lancet 1956; 267: 191.
7. Okoro SA, Patel TH, Wang PT. Who needs the surgical headlight. Cleft
Palate Craniofac. J. 2007; 44: 1268.
8. Drury NE, Pollard R, Dyer JP. Minimally invasive surgery: only as
good as the picture. Ann. R. Coll. Surg. Engl. 2004; 86: 401.
9. Bellina JH, Haas M. Cold light sources. Are they really cold. J. Reprod.
Med. 1984; 29: 2757.
10. Chahin F, Dwivedi AJ, Paramesh A et al. The implications of lighted
ureteral stenting in laparoscopic colectomy. JSLS 2002; 6: 4952.
11. Richter HO, Knez I. Superior short-wavelength contrast sensitivity in
asthenopics during reflexive readjustments of ocular accommodation.
Ophthalmic. Physiol. Opt. 2007; 27: 36172.
12. Viola AU, James LM, Schlangen LJ, Dijk DJ. Blue-enriched white
light in the workplace improves self-reported alertness, performance
and sleep quality. Scand. J. Work Environ. Health 2008; 34: 297306.
13. Cajochen C, Munch M, Kobialka S et al. High sensitivity of human
melatonin, alertness, thermoregulation, and heart rate to short wavelength light. J. Clin. Endocrinol. Metab. 2005; 90: 13116.
14. Lockley SW, Evans EE, Schleer FA et al. Short-wavelength sensitivity
for the direct effects of light on alertness, vigilance, and the waking
electroencephalogram in humans. Sleep 2006; 29: 1618.
15. Van Den Broek FJ, Reitsma JB, Curvers WL, Fockens P, Dekker E.
Systematic review of narrow-band imaging for the detection and
differentiation of neoplastic and nonneoplastic lesions in the colon.
Gastrointest. Endosc. 2009; 69: 12435.
16. Roberts WW, Dinkel TA, Schulam PG, Bonnell L, Kavoussi LR.
Laparoscopic infrared imaging. Surg. Endosc. 1997; 11: 12213.
17. Wetzel CM, Kneebone RL, Woloshynowych M et al. The effects of
stress on surgical performance. Am. J. Surg. 2006; 191: 510.
18. Arora S, Hull L, Sevdalis N et al. Factors compromising safety in
surgery: stressful events in the operating room. Am. J. Surg. 2010; 199:
605.
19. Arora S, Sevdalis N, Nestel D, Woloshynowych M, Darzi A, Kneebone
R. The impact of stress on surgical performance: a systematic review of
the literature. Surgery 2010; 147: 31830.
20. Sexton JB, Thomas E, Helmreich R. Error, stress, and teamwork in
medicine and aviation: cross sectional surveys. BMJ 2000; 320: 7459.

2010 The Authors

ANZ Journal of Surgery 2010 Royal Australasian College of Surgeons

Optimizing the operating theatre

21. Wiggins-Dohlvik K, Stewart RM, Babbitt RJ et al. Surgeons performance during critical situations: competence, confidence and composure. Am. J. Surg. 2009; 198: 81723.
22. Arora S, Sevdalis N, Nestel D et al. Managing intraoperative stress:
what do surgeons want from a crisis training program. Am. J. Surg.
2009; 197: 53743.
23. Moorthy K, Munz Y, Dosis A, Bann S, Darzi A. The effects of stressinducing conditions on the performance of a laparoscopic task. Surg.
Endosc. 2003; 17: 14814.
24. Hassan I, Weyers P, Maschuw K et al. Negative stress-coping strategies
among novices in surgery correlate with poor virtual laparoscopic performance. Br. J. Surg. 2006; 93: 15549.
25. Wetzel CM, Black SA, Hanan GB et al. The effects of stress and coping
on surgical performance during simulations. Ann. Surg. 2010; 251:
1716.
26. Blekin NL. Testing surgical gowns for the anticipated level of exposure. J. Laparoendosc. Adv. Surg. Tech. 2000; 10: 11922.
27. Leonas KK, Jinkins RS. The relationship of selected fabric characteristics and the barrier effectiveness of surgical gown fabrics. Am. J.
Infect. Control 1997; 25: 1623.
28. Leonas KK. Effect of laundering on the barrier properties of reusable
surgical gown fabrics. Am. J. Infect. Control 1998; 26: 495501.
29. Pissiotis CA, Komborozos V, Papoutsi C, Skrekas G. Factors that
influence the effectiveness of surgical gowns in the operating theatre.
Eur. J. Surg. 1997; 163: 597604.
30. Cho JS, Tanabe SI, Cho G. Thermal comfort properties of cotton and
nonwoven surgical gowns with dual functional finish. Appl. Human Sci.
1997; 16: 8795.
31. Tanner J, Parkinson H. Double gloving to reduce surgical cross infection (Review). Cochrane Database Syst. Rev. 2006; 3: Art. No.:
CD003087. DOI: 10.1002/14651858.CD003087.pub2.
32. Webb JM, Pentlow BD. Double gloving and surgical technique. Ann. R.
Coll. Surg. Engl. 1993; 75: 2912.
33. Fry DE, Harris WE, Kohnke EN, Twomey CL. Influence of doublegloving on manual dexterity and tactile sensation of surgeons. J. Am.
Coll. Surg. 2010; 210: 32530.
34. Wilson SJ, Sellu D, Uy A, Jaffer MA. Subjective effects of double
gloves on surgical performance. Ann. R. Coll. Surg. Engl. 1996; 78:
202.
35. Novak CB, Megan J, Patterson M, Mackinnon SE. Evaluation of hand
sensibility with single and double latex gloves. Plast. Reconstr. Surg.
1999; 103: 12831.
36. Woods JA, Leslie LF, Drake DB, Edlich RF. Effect of puncture resistant surgical gloves, finger guards, and glove liners on cutaneous sensibility and surgical psychomotor skills. J. Biomed. Mater. Res. 1996;
33: 4751.
37. Kracht JM, Busch-Vishniac IJ, West JE. Noise in the operating rooms
of John Hopkins Hospital. J. Acoust. Soc. Am. 2007; 121: 267380.
38. Love H. Noise exposure in the orthopaedic operating theatre: a significant health hazard. ANZ J. Surg. 2003; 73: 8368.
39. Hodge B, Thompson JF. Noise pollution in the operating theatre.
Lancet 1990; 335: 8914.
40. Healey AN, Sevdalis N, Vincent CA. Measuring intra-operative interference from distraction and interruption observed in the operating
theatre. Ergonomics 2006; 49: 589604.
41. Mendel LL, Gardino JA, Atcherson SR. Speech understanding using
surgical masks: a problem in health care? J. Am. Acad. Audiol. 2008;
19: 68695.
42. Moorthy K, Munz Y, Undre S, Darzi A. Objective evaluation of the
effect of noise on the performance of a complex laparoscopic task.
Surgery 2004; 136: 2530.

2010 The Authors

ANZ Journal of Surgery 2010 Royal Australasian College of Surgeons

923

43. Siu KC, Suh IH, Mukherjee M, Oleynikov D, Stergious N. The impact
of environmental noise on robot-assisted laparoscopic surgical performance. Surgery 2010; 147: 10713.
44. Thompson JF, Kam PCA. Music in the operating theatre. Br. J. Surg.
1995; 82: 15867.
45. Allen K, Blascovich J. Effects of music on cardiovascular reactivity
among surgeons. JAMA 1994; 272: 8824.
46. Miskovic D, Rosenthal R, Zingg U et al. Randomized controlled trial
investigating the effect of music on the virtual reality laparoscopic
learning performance of novice surgeons. Surg. Endosc. 2008; 22:
241620.
47. Fontaine CW, Schwalm ND. Effects of familiarity of music on vigilant
performance. Percept. Mot. Skills. 1979; 49: 714.
48. Rauscher FH, Shaw GL, Ky KN. Music and spatial task performance.
Nature 1993; 365: 611.
49. Rubin D, Kiss A, Wetz RV, Sottile VM. Music in the endoscopy suite:
a meta-analysis of randomized controlled studies. Endoscopy 2007; 39:
50710.
50. Ayoub CM, Rizk LB, Yaacoub CI, Gaal D, Kain ZN. Music and
ambient operating room noise in patients undergoing spinal anesthesia.
Anesth. Analg. 2005; 100: 13169.
51. Lopez-Cepero Andrada LM, Amaya Vidal A, Castro Aguilar-Tablada T
et al. Anxiety during the performance of colonoscopies: modification
using music therapy. Eur. J. Gastroenterol. Hepatol. 2004; 16: 13816.
52. Zhang XW, Fan Y, Manyande A, Tian YK, Yin P. Effects of music on
target-controlled infusion of propofol requirements during combined
spinal-epidural anaesthesia. Anaesthesia 2005; 60: 9904.
53. Nilsson U, Unosson M, Rawal N. Stress reduction and analgesia in
patients exposed to calming music postoperatively: a randomized controlled trial. Eur. J. Anaesthesiol. 2005; 22: 96102.
54. Hawksworth C, Asbury AJ, Millar K. Music in theatre: not so harmonious: a survey of attitudes to music played in operating theatre. Anaesthesia 1997; 52: 7983.
55. Hawksworth CR, Sivalingam P, Asbury AJ. The effect of music on
anaesthetists psychomotor performance. Anaesthesia 1998; 53:
1957.
56. Sanderson PM, Tosh N, Philp S et al. The effects of ambient music on
simulated anaesthesia monitoring. Anaesthesia 2005; 60: 10738.
57. Sevdalis N, Forrest D, Undre S, Darzi A, Vincent C. Annoyances,
disruptions, and interruptions in surgery: the Disruptions in Surgery
Index (DiSI). World J. Surg. 2008; 32: 164350.
58. Sevdalis N, Healey AN, Vincent CA. Distracting communications in
the operating theatre. J. Eval. Clin. Pract. 2007; 13: 3904.
59. Kurz A. Thermal care in the perioperative period. Best Pract. Res. Clin.
Anaesthesiol. 2008; 22: 3962.
60. Kurz A, Sessler DI, Lenhart I. Perioperative normothermia to reduce
the incidence of surgical-wound infection and shorten hospitalisation.
N. Engl. J. Med. 1996; 334: 120915.
61. Brauer A, Quintek M. Forced-air warming: technology, physical background and practical aspects. Curr. Opin. Anaesthesiol. 2009; 22: 769
74.
62. Wong PF, Kumar S, Bohra A, Whetter D, Leaper DJ. Randomized
clinical trial of perioperative systemic warming in major elective
abdominal surgery. Br. J. Surg. 2007; 94: 4216.
63. Vanni SM, Braz JR, Modolo NS, Amorim RB, Rodrigues GR. Preoperative combined with intraoperative skin-surface warming avoids
hypothermia caused by general anaesthesia and surgery. J. Clin.
Anaesth. 2003; 15: 11925.
64. Kim Y-S, Jeon Y-S, Lee J-A et al. Intra-operative warming with a
forced-air warmer in preventing hypothermia after tourniquet deflation
in elderly patients. J. Int. Med. Res. 2009; 37: 145764.

924

65. Jamjoon AAB, Nikkar-Esfahani A, Fitzgerald JEF. Operating theatre

related syncope in medical students: a cross sectional study. BMC Med.
Educ. 2009; 9: 14.
66. Tham KW. Effects of temperature and outdoor air supply rate on the
performance of call center operators in the tropics. Indoor Air 2004; 14:
11925.
67. Wyon DP, Andersen I, Lundqvist GR. The effects of moderate heat
stress on mental performance. Scand. J. Work Environ. Health 1979; 5:
35261.
68. Wyon DP, Lidwell OM, Williams REO. Thermal comfort during
surgical operations. J. Hyg. 1968; 66: 22948.
69. Lango T, Nesbakken R, Faerevik H et al. Cooling vest for improving
surgeons comfort: a multidisciplinary design project. Minim. Invasive
Ther. 2009; 18: 110.
70. Bhatnager V, Drury CG, Schiro SG. Posture, postural discomfort, and
performance. Hum. Factors 1985; 27: 18999.
71. Liao MH, Drury CG. Posture, discomfort and performance in a VDT
task. Ergonomics 2000; 43: 34559.
72. Kant IJ, deJong LC, van Rijssen-Moll M, Borm PJ. A survey of static
and dynamic work postures of operating room staff. Int. Arch. Occup.
Environ. Health 1992; 63: 4238.
73. Berguer R. Surgery and ergonomics. Arch. Surg. 1999; 134: 10116.
74. Berguer R, Rab GT, Abu-Ghaida H, Alarcon A, Chung J. A comparison
of surgeons posture during laparoscopic and open surgical procedures.
Surg. Endosc. 1997; 11: 13942.
75. Al-Eisa E, Egan D, Deluzio K, Wassersug R. Effects of pelvic asymmetry and low back pain on trunk kinematics during sitting: a comparison with standing. Spine 2006; 31: E135E143.
76. Bendix T, Krohn L, Jessen F, Aaras A. Trunk posture and trapezius
muscle load while working in standing, supported standing, and sitting
positions. Spine 1985; 10: 4339.
77. Galleano R, Carter F, Brown S, Farnk T, Cuschieri A. Can armrests
improve comfort and task performance in laparoscopic surgery? Ann.
Surg. 2006; 243: 32933.
78. Zheng B, Taylor MD, Swanstrom LL. An observational study of
surgery-related activities between nurses and surgeons during laparoscopic surgery. Am. J. Surg. 2009; 197: 497502.
79. Kenyon TAG, Lenker MP, Bax TW, Swanstrom LL. Cost and
benefit of the trained laparoscopic team. Surg. Endosc. 1997; 11:
8124.
80. Mitchell L, Flin R. Non-technical skills of the operating theatre scrub
nurse: literature review. J. Adv. Nurs. 2008; 63: 1524.
81. Edmondson AC. Speaking up in the operating room: how team leaders
promote learning in interdisciplinary action teams. J. Manag. Stud.
2003; 40: 141952.
82. Silen-Lipponen M, Tossavainen K, Turunen H, Smith A. Potential
errors and their prevention in operation room teamwork as experienced
by Finnish, British And American nurses. Int. J. Nurs. Pract. 2005; 11:
2132.
83. Baylis OJ, Adams WE, Allen D, Fraser SG. Do variations in the theatre
team have an impact on the incidence of complications? BMC Opthal.
2006; 6: 13.
84. Hutter MM, Glasgow RE, Mulvihill SJ. Does the participation
of a surgical trainee adversely impact patient outcomes? A study of
major pancreatic resections in California. Surgery 2000; 128: 286
92.
85. Paisley AM, Madhavan KK, Paterson-Brown S, Praseedom RK,
Garden OJ. Role of the surgical trainee in upper gastrointestinal resectional surgery. Ann. R. Coll. Surg. Engl. 1999; 81: 405.

Wong et al.

86. Mahoney A, Crowe P, Harris P. Exploring Australasian surgical trainees satisfaction with operating theatre learning using the Surgical
theatre educational environment measure. ANZ J. Surg. 16 August
2010. DOI: 10.1111/j.1445-2197.2010.05430.x (Epub ahead of print.)
87. Palan J, Gulati A, Andrew JG, Murray DW, Beard DJ. The trainer, the
trainee and the surgeons assistant. J. Bone Joint Surg. 2009; 91-B:
92834.
88. Panait L, Rafiq A, Mohammed A, Mora F, Merrell R. Robotic assistant
for laparoscopy. J. Laparoendosc. Adv. Surg. Tech. 2006; 16: 8894.
89. Hildebrandt U, Plusczyk T, Kessler K, Menger MD. Single-surgeon
surgery in laparoscopic colonic resection. Dis. Colon Rectum 2003; 46:
16405.
90. Poulose BK, Kutka MF, Mendoza-Sagaon M et al. Human vs robotic
organ retraction during laparoscopic Nissen fundoplication. Surg.
Endosc. 1999; 13: 4615.
91. Gaba DM, Howard SK. Fatigue among clinicians and the safety of
patients. N. Engl. J. Med. 2002; 347: 124955.
92. Weinger MB, Ancoli-Israel S. Sleep deprivation and clinical performance. JAMA 2002; 287: 9557.
93. Eastridge BJ, Hamilton EC, OKeefe GE et al. Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. Am.
J. Surg. 2003; 186: 16974.
94. Olson EJ, Drage LA, Auger RR. Sleep deprivation, physician performance, and patient safety. Chest 2009; 136: 138996.
95. Rothschild JM, Keohane CA, Rogers S et al. Risks of complications
by attending physicians after performing nighttime procedures. JAMA
2009; 302: 156572.
96. Leff DR, Aggarwal R, Rana M et al. Laparoscopic skills suffer on the
first shift of sequential night shifts: program directors beware and
residents prepare. Ann. Surg. 2008; 247: 5309.
97. Pilcher JJ, Huffcutt AI. Effects of sleep deprivation on performance: a
meta-analysis. Sleep 1996; 19: 31826.
98. Kahol K, Leyba MJ, Deka M et al. Effect of fatigue on psychomotor
and cognitive skills. Am. J. Surg. 2008; 195: 195204.
99. Gerdes J, Kahol K, Smith M, Leyba MJ, Ferrara JJ. The effect of
fatigue on cognitive and psychomotor skills of trauma residents and
attending surgeons. Am. J. Surg. 2008; 196: 81320.
100. Kuhn G. Circadian rhythm, shift work, and emergency medicine. Ann.
Emerg. Med. 2001; 37: 8898.
101. Edwards BJ, Lindsay K, Waterhouse J. Effect of time of day on the
accuracy and consistency of the badminton serve. Ergonomics 2005;
48: 148898.
102. De Mello MT, Esteves AM, Pires ML et al. Relationship between
Brazilian Airline pilot errors and time of day. Br. J. Med. Biol. Res.
2008; 41: 1129.
103. Wright MC, Phillips-Bute B, Mark JB et al. Time of day effects on the
incidence of anesthetic adverse events. Qual. Saf. Health Care 2006;
15: 25863.
104. Aya AG, Mangin R, Robert C et al. Increased risk of unintentional
dural puncture in night-time epidural obstetric epidural anesthesia.
Can. J. Anaesth. 1999; 46: 6659.
105. Tan PJ, Xu M, Sesslet DI, Bashour A. Operation timing does not affect
outcome after coronary artery bypass graft surgery. Anesthesiology
2009; 111: 7859.
106. Seow YY, Alkari B, Dyer P, Riad H. Cold ischemia time, surgeon, time
of day, and surgical complications. Transplantation 2004; 77: 13869.
107. Chang WC, Lin CC, Chen LM, Wu HD, Yeh LS, Lin LY. Schedule
effect and laparoscopic-assisted vaginal hysterectomy. Aust. N. Z. J.
Obstet. Gynaecol. 2008; 48: 4337.

2010 The Authors

ANZ Journal of Surgery 2010 Royal Australasian College of Surgeons