The Impact of Two Operating Surgeons on Microsurgical Breast Reconstruction

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We read the article by Weichman et al. with great interest.1 We strongly agree that we should strive to improve operating room efficiency with shorter operating times, as this translates into shorter hospital length of stay and improved outcomes. Although having two attending (consultant) surgeons is an excellent option, this can be difficult to routinely adopt in health care settings where the availability of a second senior surgeon is limited, such as the United Kingdom National Health Service.
As a high-volume microsurgical center, we wish to share our experience of using the microsurgery fellow to maintain operating room efficiency concurrently with microsurgical training using two operators (attending and fellow, as opposed to four surgeons in Weichman et al.’s1 experience consisting of two attending surgeons and two trainees). The microsurgery fellow is a senior plastic surgery trainee in the peri-final year (6 or 7) of plastic surgery training. Our current model involves a “process-mapping” approach similar to that described by Marsh et al.,2 albeit incorporating the fellow as an integral component of the procedure. The intricacies of precision planning and orchestration of the dynamic operative sequences of this two-man team approach are fundamental to operating room efficiency (Fig. 1). While the breast surgeons perform the mastectomy, our team begins flap raising of a hemiabdomen based on the best perforator(s) selected on computed tomographic angiography. Raising the flap is often complete by the time the mastectomy/clearance is completed. The fellow prepares the internal mammary vessels while the attending surgeon concurrently begins deepithelialization of the DIEP while it remains in situ. Once the flap is divided, it is handed out to be weighed and, during this time, rectus sheath closure commences. Once the microsurgery begins, abdominal closure concurrently ensues.
We also strongly feel that having regular, consistent scrub/nurse teams plays a crucial role in maximizing operating room efficiency, as frequent changes have a negative impact on surgical performance.3 For this reason, we use two consistent and concurrent teams at any time.
Using the above model, we achieve similar operative times and complication rates as reported by Weichman et al.,1 with no compromise to training. We believe that reducing operative times is about time management in the operating room by the senior surgeon, specifically to ensure that different parts of the procedure are carried out concurrently. We believe our model is more applicable to health care systems with limited resources.

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