Gynaecologists’ and general surgeons’ preference for the features of integrated theatres: a discrete choice experiment

Laparoscopic surgery has advanced due to improvements in both surgical technique and technical innovations. This has placed additional demands on the surgical environment and theatre design has mirrored these changing demands [1]. An ergonomic theatre design may improve team performance [2] as surgeons have been shown to have improved laparoscopic task performance when screens are directly ahead and below eye level, rather than to the side [3]. This ergonomic improvement in operating theatres reduces the risk of harm to the theatre team and patient, from potential electrical, mechanical and biological hazards [2, 4‐8]. The reduction in theatre nurses’ tasks may reduce physical and mental workload and improve patient safety and job satisfaction [9]. A stressful theatre environment impairs dexterity and increases the incidence of errors [10]. Integrated theatres potentially result in a reduction in stress for the operating team [11] and enhanced efficiency during operations [12]. Thus it is likely that this less stressful theatre environment may improve patient safety. It has also been suggested that integrated theatres improve efficiency [13, 14]. However integrated theatre systems are expensive to buy and install as they require structural works to support the pendants and install the linkage between the different elements. Further hidden costs are surgical downtime during the installation process when the theatre is out of action. Average estimated costs are £0.5 million for the purchase and installation of the average high-level system but the costs can vary greatly due to different building structures that are in place before the installation. There are now alternatives to fully integrated laparoscopic theatres with floor mounted mobile systems where up to 8 screens can be wirelessly linked and positioned around the operating room as required. In addition modern camera heads enable many of the controls of a touch screen to be carried out directly from the camera head buttons. This creates a realistic alternative to the fully integrated system and may mean that the benefits of these systems can be delivered more cheaply. For these reasons it is important to understand which attributes of the currently sold laparoscopic integrated theatres are favoured by the surgeons who work in them.

A previous study [15] showed that the attributes of laparoscopic theatres which gynaecologists rated most highly, however, this study did not investigate the strength of the preference for these features, which is useful to judge how highly they are valued. In this study we chose to use a discrete choice experiment (DCE) to determine the relative importance placed on specific attributes of laparoscopic theatres as this is the best measure of how highly attributes are valued. By asking participants to choose between a series of hypothetical options with varying attributes, DCE’s reveal which attributes influence choice behaviour, establish an individual’s willingness to trade-off one attribute against another and as a result provide an insight into real-life decision making [16, 17]. The aim of this study was to assess the strength of preference for key attributes of integrated laparoscopic theatres and to compare these preferences between Gynaecologists and General surgeons.

The study design and analysis followed current guidelines for conducting DCEs [18]. A pilot questionaire was conducted with five laparoscopic gynaecological surgeons from within the department and the findings were used to improve the finalised version of the questionnaire.

Questionnaires from 167 respondents were analysed. One hundred three were gynaecologists (out of 639 invited 16.1%) and 64 were general surgeons (out of 533 invited 12.0%). For gynaecologists 66/103 (64.1%) were male and 37/103 (35.9%) were female and for the general surgeons these figures were 57/64 (89.1%) and 7/64 (10.9%) respectively. For both groups together this means that 123/167 (73.7%) were male and 44/167 (26.3%) were female.

For gynaecologists 72/103 (69.9%) were Consultants and 31/103 (30.1%) were Doctors in training and for the general surgeons these figures were 51/64 (79.7%) and 13/64 (20.3%) respectively. For both groups together 123/167 (73.7%) were Consultants with 44/167 (26.3%) Doctors in training.

Respondents were asked how often they carried out laparoscopic surgery. 81/167 (48.5%) performed major laparoscopic surgery every week, 31/167 (18.6%) every 2 weeks and 55/167 (32.9) once a month or less.

Table 1 shows the results for the conditional logit analysis regression for both Gynaecologists and General Surgeons combined. Adjustable screens for height and position was the most favoured attribute and it is nearly 5 times more desirable than the next most desirable attribute, which was a wire free floor (MRS = 1.584/0.335 = 4.7). The least desirable features were piped CO2, ceiling mounted screens and external transmission of images the presence or absence of which did not significantly affect participants decision-making.

Table 1 also shows the results for the conditional logit analysis regression for both Gynaecologists and General Surgeons analysed separately and compared. This shows that the most desirable four features are the same and in the same order for both groups. General surgeons were statistically significantly more likely than gynaecologists to value adjustable screens over the other attributes. The MRS is also similar for both groups (gynaecologists = 5.0, general surgeons = 4.2). Although there appears to be disagreement between the groups on the order of the least desirable 3 features, none of these significantly affected decision-making.

Table 2 shows the results for the conditional logit analysis regression for male and female participants analysed separately and compared. This shows that male and female participants agreed on the three most desirable features and in the same order. There were no significant differences when comparing the choices of male and female participants.

There were no statistically significant differences when consultants were compared with Doctors in training and when more experienced participants were compared with less experienced participants.

Table 3 shows the geographical spread of BSGE responders and BSGE members overall. Chi squared for an 8 × 2 table of difference between the location of the survey responders and the location of all BSGE members gave Chi-square = 8.93, probability P = 0.257. This shows that the geographical variation of the respondents was representative of the BSGE membership as a whole. Table 4 shows an example question in the DCE.

This is the first study to use a discrete choice experiment to assess the features of integrated laparoscopic theatres that surgical personnel favour. It is also the first study to compare different choices that exist between general surgeons and gynaecologists regards laparoscopic theatres.

The integrated laparoscopic theatre is a state-of-the-art system in which multiple flat-screen monitors and other laparoscopic equipment are permanently installed to be operational on demand inside the theatre. This system facilitates versatile positioning of equipment as they are installed on columns attached to a ceiling-mounted suspension system. All the wiring is concealed inside the suspension system and led out through the ceiling which reduces operating room clutter and improves safety [4, 24]. The CO2 gas, rather than utilising small canisters, is piped on demand thus reducing the time needed to change canisters and the resultant loss of a pneumoperitoneum that goes with loss of gass. The surgeon and theatre staff are able to control the laparoscopic and theatre room equipment using touch screen monitors. This is in contrast to the traditional laparoscopic systems with one, non adjustable screen which is mounted on top of a floor mounted stack of equipment which can be wheeled into theatre as required.

Generally there was agreement between general surgeons and gynaecologists with the same four attributes favoured in the same order. Both groups favour adjustable screens for position and height above all the other features with general surgeons more strongly favouring this attribute than gynaecologists. These findings are in contrast with the findings of our previous study, which showed that when asked to rank the attributes in order, gynaecologists chose ceiling mounted screens first and adjustable screens fourth. When asked to “trade off” attributes in the discrete choice experiment the adjustability of the screens became much more important than how the screens were mounted.

The findings of our study suggest that the main benefit of integrated laparoscopic theatres is the ability to position the screens almost anywhere in the theatres. Due to wireless technology, floor mounted systems could be designed to function in the same way as current integrated theatres. This removes the need for expensive building works and long theatre down time during installation. Thus the modern laparoscopic theatre could be delivered at a considerably reduced cost. This information is important to manufacturers and purchasers of these systems in order to design cost effective ergonomic theatres that are fit for purpose. Thus the advent of wireless connectivity technology with monitors on slim versatile stands enables the market place to be expanded at a much reduced cost.

Both groups favour adjustable screens for position and height above all the other features. These findings are in contrast with previous research, which showed that when asked to rank the attributes in order, gynaecologists chose ceiling mounted screens first and adjustable screens fourth. When asked to “trade off” attributes in the discrete choice experiment the adjustability of the screens became much more important than how the screens were mounted. With new wireless technology the benefits of a fully integrated theatre could be delivered with floor mounted systems at a considerably reduced cost. This information is important to manufacturers and purchasers of these systems in order to design cost effective ergonomic theatres that are fit for purpose.