The efficiency of microsurgical breast reconstruction. A single centre prospective comparator blinded cohort study

Background: The demand to improve the efficiency of microsurgical breast reconstruction is driven by increasing numbers of breast cancer and risk reducing cases, as well as the concurrent requirement for hospitals to cut costs. Businesses have successfully used process mapping as a tool to improve efficiency, however process mapping has been sparsely used in surgery. The DIEP flap is deemed the gold standard of microsurgical breast reconstruction in suitable women after mastectomies. There has been a paucity of data in the literature regarding process mapping and surgery – the majority of which is aimed at improving flow through a hospital or turnover times between operations in the operating theatre. This prospective comparator pilot study has used process mapping to break down the individual components of a deep inferior epigastric artery perforator (DIEP) flap operation into a template of 100 streamlined steps. As such it is the first study to process map a long operation into its individual steps. This study then demonstrates if process mapping can improve the efficiency of a long operation such as the DIEP flap. Methods: St Andrew’s Centre for Burns and Plastic Surgery is one of the world’s leading centres for plastic surgery including microsurgical breast reconstruction. Through observation of one of the senior surgeon’s uniform technique, refined from experience of over 5000 cases, the DIEP flap operation was broken down into 100 individual steps, all arranged in a logical sequence with which to maximise efficiency and outcome. This created a 100-step process-mapped template. Ethical approval was granted from the hospital as there was no patient safety concerns and no different equipment being used. Anglia Ruskin University ethical approval was also sought and granted. Subsequently, two cohorts of ten unilateral DIEP cases were prospectively timed. One cohort following this process mapped template and the other comparator group was blinded to the template. A further prospective study is used to time two cohorts of ten unilateral DIEP patients each timing trainees in raising the DIEP flap. Cohort 1 trainee follows the process mapped template whilst the trainee in Cohort 2 is blinded to the template. Results: The first process mapped cohort had a mean of 56.1 minutes total operative time and 77 minutes of total operation room time quicker than the first comparator cohort, despite the addition of symmetrising surgery being performed concurrently in four out of the ten cases. Only one return to theatre in the comparator group with no flap loss in either group. The process mapped cohort in 7/13 grouped steps timed were statistically significantly more efficient than the blinded control cohort time. The 100 step template was used to time trainees performing these operations or major parts of them – namely raising the DIEP flap. The process mapped trainee cohort was quicker by 42 minutes on average of mean total times of ten cases of DIEP Flap raising compared with the comparator trainee cohort blinded to the template and this was also statistically significant. No flap failure in either cohort. Conclusions: This study presents a novel approach to process map the DIEP flap operation. In so doing it is the first in the literature to process map a large operation as well as demonstrates its utility in improving operative efficiency with statistical significance and without flap loss at six weeks post-surgery assessment. This leads to benefits for patients, surgeons and hospitals. It also illustrates the possibility of symmetrising surgery being carried out through parallel operating processes, without affecting overall operative times as well as enabling multiple operations being carried out in a fixed period of time. The study also demonstrates the use of process mapping as a training tool to improve efficiency. It is also a useful data resource to analyse variance in one owns practice as well as comparatively between peers.