Surgical Gesture Utilization and Efficacy Trends Between Retractions in Surgeons Performing the Robot-Assisted Nerve-Sparing Prostatectomy

Objective: Surgical gestures, defined as the smallest meaningful interactions of surgical instruments with tissue, are a novel approach to objectively deconstruct surgery. We have previously classified gestures among three major categories: blunt, sharp, and supporting. Retraction is a supporting gesture, which involves placing tissue on stretch to gain better access to surgical site and to allow tension for effective tissue dissection. We aim to assess utilization and efficacy trends of gestures between these retractions, based on surgeon experience and the anatomical location where gestures are performed. Methods: Robotic prostatectomy surgical videos from two centers were captured and manually annotated to identify each surgical gesture, its efficacy and anatomical location, using a classification system previously published. Surgeons were separated by median split-high experience (HE) vs low experience (HE). Sequences of gestures within each sequential retraction gesture were labeled as retraction units (RUs). RUs were split equally into quartiles based on number of gestures in that RU and trends in gesture efficacy were described. Results: Overall, 61 surgical videos were annotated to identify 21,045 gestures. Median gestures per case were 222 (interquartile range [IQR]: 163-364) and 337 (IQR: 222-398) for surgeons with HE and LE, respectively. HE surgeons had fewer RUs (p < 0.001), higher gestures per RU (p = 0.031) and greater gesture efficacy (p = 0.023) per RU. There was a significant decline in gesture efficacy for blunt gestures as evaluated from first to last quartile within each RU (p < 0.001). This decline was evident for both HE (p < 0.001) and LE surgeons (p = 0.009) and irrespective of the anatomical location (pedicle, p = 0.04; lateral fascia, p = 0.01). Conclusion: Experienced surgeons demonstrated higher gesture efficacy, fewer retractions, and more gestures per RU. Decline in gesture efficacy for blunt gestures is apparent across each RU irrespective of surgeon experience and anatomical location, suggesting re-retract during dissection is an active and dynamic activity.