Standardized instrument setup shortens operating time and reduces interruptions in laparoscopic gastrointestinal surgery: A single-centre randomized control trial

Abstract

BACKGROUND

Laparoscopic gastrointestinal surgery instruments are complex, and traditional management models rely on nurses’ personal experiences, which can easily lead to intraoperative interruptions. Standardized instrument settings aim to improve team collaboration, efficiency, and surgical safety through a unified process.

AIM

To explore the application of an operating room nurse-led standardized laparoscopic instrument setup model to optimize laparoscopic gastrointestinal surgery.

METHODS

A total of 120 patients undergoing laparoscopic gastrointestinal surgery between June 2022 and June 2025 were divided into observation (n = 60) and control (n = 60) groups using the random number table method. The control group adopted the traditional instrument management model. The observation group implemented a standardized instrument setup (SIS) scheme formulated under the leadership of operating room nurses. Surgical efficiency indicators, clinical outcome indicators, postoperative complication rates, team subjective evaluations, and cognitive load levels were compared between groups.

RESULTS

Compared with the control group, the observation group showed shorter median operating-room occupancy time (185.6 ± 28.4 minutes vs 205.3 ± 32.1 minutes, P < 0.001), surgical preparation time (18.5 ± 3.2 minutes vs 25.8 ± 4.7 minutes, P < 0.001), and core surgical time (152.7 ± 25.6 minutes vs 168.9 ± 30.3 minutes, P = 0.001). Unplanned interruptions decreased (4.6 ± 1.5 events per case to 1.2 ± 0.8 events per case, P < 0.001), including instrument-related interruptions (2.8 ± 1.1 to 0.5 ± 0.7, P < 0.001) and communication-related interruptions (1.1 ± 0.8 to 0.3 ± 0.5, P < 0.001). Effective instrument handover rate increased (95.2% to 99.1%, P < 0.001), and mean handover time decreased (2.8 ± 0.6 seconds to 1.5 ± 0.3 seconds, P < 0.001). Post-operative overall complication rate reduced (25.0% to 10.0%, χ² = 4.675, P = 0.031).

CONCLUSION

Nurse-led SIS can significantly operative efficiency, reduce invalid operations and unplanned interruptions, and improve the overall collaborative tacit understanding and work efficiency, supporting further clinical promotion and application.

Key Words: Operating room nurse; Instrument standardization; Laparoscopic surgery; Gastrointestinal surgery; Process optimization; Team collaboration

Core Tip: This study demonstrated that an operating room nurse-led standardized instrument setup (SIS) model significantly enhanced the efficiency of laparoscopic gastrointestinal surgery. Compared to the traditional experience-based approach, the SIS reduced operating room occupancy time, unplanned interruptions, and instrument handover errors, while improving patient outcomes and lowering the cognitive load for surgeons and scrub nurses. This nurse-driven, standardized protocol optimizes workflow and team collaboration and offers a reproducible model for improving surgical safety and efficiency.

INTRODUCTION

With the rapid development of minimally invasive surgical techniques, laparoscopic surgery has become a mainstream approach for treating gastrointestinal diseases. It is favored by both patients and surgeons because of its advantages, including minimal trauma, rapid postoperative recovery, and shorter hospital stays[1,2]. However, the successful implementation of laparoscopic surgery depends heavily on complex and sophisticated equipment, a wide variety of surgical instruments, and efficient, precise, and seamless collaboration among the entire surgical team[3,4]. In this intricate, systematic engineering process, the management and transfer of surgical instruments play a crucial “hub” role; their efficiency and quality directly affect the smoothness, safety, and ultimately the surgical outcome[5,6].

The traditional management of laparoscopic gastrointestinal surgical instruments relies primarily on the personal work experience, habitual memory, and on-the-spot responsiveness of scrub nurses, representing an experience-based model. In prolonged and high-intensity laparoscopic gastrointestinal surgeries, frequent and rapid instructions from surgeons may overwhelm nurses, leading to unplanned interruptions, including instrument transfer errors, delays, and instrument drops. These issues not only disrupt the surgical rhythm and prolong the operative time but may also increase the intraoperative risks for patients[7,8]. Enhancing team collaboration efficiency through process optimization, while ensuring surgical safety, has become a key challenge in current operating room management.

In recent years, the management philosophy in operating rooms has transitioned from experience-based management to a scientific, systematic, and process-centered approach, with standardization emerging as the core strategy for improving surgical quality and ensuring patient safety[9-11]. In this context, a safety instrumented system (SIS) serves as the key entry point for optimizing the surgical process. Establishing scientific, unified, and standardized procedures for instrument placement, transfer, and management helps minimize uncontrollable human factors, making surgical collaboration predictable, repeatable, and highly efficient[12,13]. As the primary managers and users of surgical instruments, operating room nurses possess a deep understanding of various surgical steps, surgeon preferences, and instrument characteristics, giving them distinct professional advantages and proactive initiative[14-16]. Therefore, for operating room nurses, leading and implementing a scientific and standardized instrument management model based on clinical needs holds significant theoretical and practical importance for optimizing laparoscopic surgical processes and enhancing the level of team collaboration.

Based on the above background, this study aimed to explore the application effects of an operating room nurse-led standardized laparoscopic instrument setup model to optimize laparoscopic gastrointestinal surgical processes, improve surgical team collaboration efficiency, and enhance team satisfaction, thereby providing evidence to support refinement and professionalization of operating room nursing management.

MATERIALS AND METHODS

Study populations

Approved by the Ethics Committee of our hospital, a total of 120 patients who underwent laparoscopic gastrointestinal surgery in our hospital from June 2022 to June 2025 were enrolled in the study.

Inclusion criteria: (1) Aged ≥ 18 years; (2) Clear preoperative diagnosis requiring elective laparoscopic radical gastrectomy, laparoscopic radical colorectal cancer surgery, or other major gastrointestinal surgeries; (3) American Society of Anesthesiologists (ASA) physical status classification grade 1-3; and (4) Patients provided informed consent and signed the consent form.

Exclusion criteria: (1) A history of major upper abdominal surgery with expected severe intra-abdominal adhesions; (2) Complicated with severe cardiac, pulmonary, hepatic, or renal dysfunction that could not tolerate surgery; (3) Conversion to open surgery during the operation; and (4) Incomplete clinical data.

Patients were divided into observation and control groups using a random number table method, with 60 patients in each group. There were no statistically significant differences in baseline data (such as age, sex, body mass index, and ASA grade) between the two groups (P > 0.05), indicating comparability (Table 1).

Table 1 Comparison of baseline data between the two groups, n (%).

Group	n	Sex		Age (year)	BMI (kg/m²)	ASA grade
		Male	Female			II	II	IV
Observation	60	36 (60.00)	24 (40.00)	58.7 ± 10.3	23.2 ± 2.8	12 (20.00)	38 (63.33)	10 (16.67)
Control	60	33 (55.00)	27 (45.00)	60.1 ± 11.5	22.9 ± 3.1	15 (25.00)	35 (58.33)	10 (16.67)
χ2/t	-	0.309		0.702	0.577	0.536
P value	-	0.578		0.484	0.565	0.765

BMI: Body mass index; ASA: American Society of Anesthesiologists.

Study methods

Methods for the control group: An traditional, experience-based instrument management model was adopted. Staff training and onboarding were conducted through an apprenticeship-based “follow-the-operation” model. The scrub nurses prepared surgical instruments by type based on their own experiences and habits, without fixed or unified standards for instrument placement. Instrument handover relied on the nurse’s passive response after hearing the surgeon’s instructions. In the case of emergencies, such as instrument malfunctions, handling mainly depended on nurses’ personal on-site responsiveness (Table 2).

Table 2 Specific content of the instrument management plan for the control group (traditional mode).

Dimension	Specific plan description	Potential problem analysis
Management philosophy	Instrument preparation and management are centered on the scrub nurse’s personal working memory, habits, and preferences	High variability, making it difficult to ensure the stability and consistency of quality
Instrument table layout	(1) No zoning planning: Instruments are placed without a fixed functional area division; (2) Disordered placement: Instruments are often piled up by model or type (e.g., all grasping forceps placed together); and (3) Random orientation: Instrument handles face different directions, with mixed front and reverse positions	Increases search time, raises the risk of taking the wrong instrument, and is not ergonomic. This leads to more unnecessary movements and higher fatigue levels for nurses
Instrument preparation logic	(1) Classify and place instruments of the same category (e.g., all grasping forceps, all dissecting forceps); and (2) When a specific instrument is needed during surgery, the surgeon gives an instruction, and the nurse then selects, identifies, and passes the instrument from the same category	Response lag and low passing efficiency. Delays are likely to occur during emergency or complex procedures
Handover and communication method	(1) Dependence on verbal instructions: Fully relies on the surgeon’s verbal requests (e.g., “Give me that long curved forceps”); (2) No confirmation process: There is usually no verbal confirmation or status check during handover; and (3) Possible communication ambiguity: Instructions may be misunderstood due to environmental noise or inconsistent terminology	High communication costs and high error risks. Surgical noise may mask instructions, leading to handover errors or delays, which affect the surgical rhythm and team morale
Staff training and onboarding	(1) Observational learning: New nurses learn by observing the operations of different senior nurses; (2) Diverse habits: Habits and methods of different trainers may conflict with each other; and (3) No standard assessment: Qualification for on-the-job work mainly depends on the subjective judgment of trainers	Long learning curve and unstable training outcomes. New nurses tend to be confused by different habits and find it hard to form a unified and efficient working mode
Emergency and special situation handling	When encountering instrument failures, the need for rare instruments, or sudden changes in surgical plans, it fully depends on the scrub nurse's personal experience, memory, and on-site adaptability	Insufficient preparation for emergency situations, making it easy to make mistakes in a hurry and prolong the surgical interruption time

Methods for the observation group: A SIS protocol formulated under the leadership of operating room nurses was implemented. The specific measures are as follows: (1) Establish an SIS special team: Led by the head nurse, 5 senior scrub nurses proficient in laparoscopic gastrointestinal surgery and 2 surgeons were selected to form the team; (2) Through a literature review, video analysis (recording and replaying previous surgical videos), and brainstorming, each step of laparoscopic gastrointestinal surgery-from pneumoperitoneum establishment, exploration, dissection, transection, anastomosis, and hemostasis to abdominal closure-was systematically decomposed. The specific contents of the instrument management plan for the observation group are shown in Table 3; (3) Based on surgical steps and instrument usage frequency, a standardized instrument table layout was developed following the principles of “zoning, layering, fixed placement, and positioning”. The table is divided into high-, medium-, and low-frequency/standby areas. The instruments were sorted by function with a uniform orientation (handles facing the nurse for easy grasping); (4) Corresponding process-specific kits (PSK) were established for surgical phases such as pneumoperitoneum establishment, dissecting anatomy, and anastomosis preparation. Before the surgery entered a certain phase, the PSK for the next phase was prepared in advance to achieve “instruments-waiting-for-the-step” rather than “steps-waiting-for-instruments” workflow; (5) Standardized movements and verbal commands for instrument handovers were defined, and a standardized passing protocol (SPP) was established to ensure rapid, accurate, and safe instrument handovers; (6) All operating room nurses participating in the study received two weeks of intensive training and simulation drills on the SIS protocol. They were allowed to work onsite only after fully mastering the protocol and passing the assessment; and (7) A standardized emergency response process was established, clarifying the handling steps and responsibility division for emergencies such as instrument malfunctions, needs for rare instruments, or sudden changes in surgical plans. This ensures a rapid and effective response to minimize surgical interruption time (Table 2).

Table 3 Specific content of the instrument management plan for the observation group (safety instrumented system mode).

Dimension	Specific plan description	Analysis of plan advantages
Management philosophy	Process-oriented management centering on the optimized surgical process, solidify best practices into standard operating procedures to ensure stable and reliable instrument management quality for each surgery	Repeatability and stability: Minimize variations caused by human factors to the greatest extent and ensure a baseline for the quality of collaborative work
Instrument table layout	Standardized zoned positioning layout: (1) High-frequency operation area: The area closest to the nurse directly in front, where high-frequency instruments (e.g., main operating trocar, atraumatic grasping forceps, dissecting forceps, electric hook/ultrasonic scalpel) are placed; (2) Medium-Frequency operation area: The areas on both sides of the high-frequency area, where medium-frequency instruments (e.g., needle holders, scissors, suction devices, Hem-o-lok forceps) are placed; (3) Low-frequency/standby area: The distal end of the instrument table, where special and standby instruments (e.g., stapler components, special retractors) are placed; and (4) Uniform orientation: All instrument handles face the nurse, and the functional jaws are oriented in the same direction, maintained in a “ready for handover” state	Fixed positioning and ergonomic compliance: Greatly shorten the search path and decision-making time, reduce unnecessary movements such as turning around and bending over, lower the nurse’s workload, and improve handover speed
Instrument preparation logic	Process-specific kits: (1) Pneumoperitoneum establishment kit: Pneumoperitoneum needle, first trocar, laparoscope, pneumoperitoneum tube; (2) Dissection and anatomy kit: Ultrasonic scalpel, dissecting forceps, atraumatic grasping forceps, suction device; (3) Anastomosis preparation kit: Stapler, cutting stapler, needle holder, suture thread; and (4) Predictive preparation: Nurses, based on the surgical progress, place the PSK for the next stage within easy reach before the current stage is about to end	Concurrent engineering and proactive preparation: Transform “passively waiting for instructions” into “proactively anticipating needs” to achieve the state of “instruments waiting for the surgeon”. Fundamentally reduce waiting-related interruptions during surgery and ensure extremely smooth processes
Handover and communication method	Standardized passing protocol: (1) Silent tacit handover: For high-frequency instruments (e.g., ultrasonic scalpel, dissecting forceps), form a conditioned reflex through training where the nurse hands over the instrument as soon as the surgeon reaches out; (2) Verbal confirmation handover (ticket-style): When handing over special or valuable instruments, clearly report the name and status (e.g., linear cutting stapler, green staple cartridge installed), and the surgeon must give a brief confirmation (e.g., Okay) upon receipt; and (3) Closed-loop communication: Ensure instructions are clearly received and correctly executed	Noise reduction, efficiency improvement, and safety enhancement: Reduce noise interference and the risk of mishearing caused by verbal instructions. Closed-loop communication significantly improves the accuracy and safety of information transmission. Silent tacit understanding greatly enhances team cohesion and surgical rhythm
Staff training and onboarding	Systematic training and certification: (1) Theoretical training: Learn the concept of the SIS plan, layout diagrams, PSK lists, and SPP processes; (2) Simulation drills: Conduct high-intensity, repetitive drills in a simulated operating room until muscle memory is formed; and (3) Assessment and certification: Formulate objective scoring criteria (e.g., preparation time, handover accuracy), and only those who achieve a 100% passing rate in the assessment are eligible for on-the-job qualification	Shortened growth cycle: Enable new nurses to get rid of dependence on specific trainers, quickly reach a qualified level through standardized training, and ensure the homogenization and high level of the overall collaborative quality of the team
Emergency and special situation handling	Standardized emergency procedures: (1) Instrument malfunction: Immediately activate standby instruments, move the malfunctioning instrument to a specific area, and handle it uniformly after the surgery; (2) Additional instrument request: Circulating nurses quickly locate and hand over instruments according to the pre-set “Instrument List” to avoid blind searching on the sterile table; and (3) Surgical procedure change: Initiate the pre-determined “expanded instrument kit” procedure	Note: The original table lacks content for “analysis of plan advantages” in this dimension. It is recommended to supplement relevant advantages based on actual scenarios, such as “clear response guidelines: Ensure rapid, orderly, and error-free handling of emergencies, minimize surgical delays caused by unexpected situations, and enhance the team’s ability to respond to risks”

Surgical efficiency indicators

(1) Operating room occupancy time: Total time from the patient’s entry into the operating room to their departure; (2) Surgical preparation time: Time from the patient’s entry into the operating room to the surgical skin incision; (3) Core surgical time: Time from skin incision to completion of skin suture; (4) Intraoperative unplanned interruptions: Total number of events causing surgical process suspension for more than 10 seconds, their causes, and interruption duration; and (5) Instrument handover efficiency: Number of instrument handovers from scrub nurses to surgeons in a single operation, effective handover rate, and average handover time.

Clinical outcome indicators

The recorded indicators included intraoperative blood loss, incidence of intraoperative adverse events, length of postoperative hospital stay, time to first ambulation, and time to first anal exhaustion/defecation.

Postoperative complication rate

Complications included postoperative fever, surgical site infection, pulmonary infection, anastomotic leakage, intestinal obstruction, and deep vein thrombosis.

Team subjective cognitive load

The NASA Task Load Index (NASA-TLX) was used to assess the subjective cognitive load of surgeons and scrub nurses during surgery. It comprises six dimensions: Mental, physical, temporal, performance, effort, and frustration. The scores range from 0 to 100, with higher scores indicating a heavier cognitive load.

Statistical analysis

SPSS software (version 26.0) was used for the data analysis. Measurement data were expressed as mean ± SD, and count data were expressed as n (%). Inter-group comparisons were conducted using the independent samples t-test and χ² test, respectively. Statistical significance was set at P value < 0.05.

RESULTS

Comparison of surgical efficiency indicators between the two groups

The surgical efficiency in the observation group was significantly higher than that in the control group. Specifically, the operating room occupancy time (185.6 ± 28.4 minutes vs 205.3 ± 32.1 minutes, P < 0.001), surgical preparation time (18.5 ± 3.2 minutes vs 25.8 ± 4.7 minutes, P < 0.001), and core surgical time (152.7 ± 25.6 minutes vs 168.9 ± 30.3 minutes, P = 0.001) were all significantly shorter in the observation group.

Furthermore, the observation group exhibited fewer intraoperative disruptions than the control group. The total number of unplanned interruptions was markedly lower in the observation group (1.2 ± 0.8 times vs 4.6 ± 1.5 times, P < 0.001), with reductions seen in both instrument-related (0.5 ± 0.7 times vs 2.8 ± 1.1 times, P < 0.001) and communication-related interruptions (0.3 ± 0.5 times vs 1.1 ± 0.8 times, P < 0.001). Consequently, the average interruption duration was also shorter in the observation group (15.3 ± 5.2 seconds vs 28.7 ± 10.4 seconds, P < 0.001).

With regard to instrument handover, the observation group demonstrated higher efficiency. The total number of handovers was lower (85.6 ± 12.4 times vs 112.3 ± 18.9 times, P < 0.001), while the effective handover rate was higher (99.1 ± 0.9% vs 95.2 ± 2.3%, P < 0.001). The average time required per handover was also significantly shorter (1.5 ± 0.3 seconds vs 2.8 ± 0.6 seconds, P < 0.001) (Tables 4 and 5).

Table 4 Comparison of surgical efficiency indicators between the two groups.

Group	Operating room occupancy time (minutes)	Surgical preparation time (minutes)	Core surgical time (min)	Total number of unplanned interruptions (times)	Instrument-related interruptions (times)
Observation group (n = 60)	185.6 ± 28.4	18.5 ± 3.2	152.7 ± 25.6	1.2 ± 0.8	0.5 ± 0.7
Control group (n = 60)	205.3 ± 32.1	25.8 ± 4.7	168.9 ± 30.3	4.6 ± 1.5	2.8 ± 1.1
t value	3.628	10.117	3.278	7.112	6.854
P value	< 0.001	< 0.001	0.001	< 0.001	< 0.001

Table 5 Comparison of communication interruption and handover efficiency during the handover of surgical instruments between two groups.

Group	Communication-related interruptions (times)	Average interruption duration (seconds)	Total number of instrument handovers (times)	Effective handover rate (%)	Average handover time (seconds)
Observation group (n = 60)	0.3 ± 0.5	15.3 ± 5.2	85.6 ± 12.4	99.1 ± 0.9	1.5 ± 0.3
Control group (n = 60)	1.1 ± 0.8	28.7 ± 10.4	112.3 ± 18.9	95.2 ± 2.3	2.8 ± 0.6
t value	5.123	6.225	9.458	12.341	15.327
P value	< 0.001	< 0.001	< 0.001	< 0.001	< 0.001

Comparison of clinical outcome indicators between the two groups

The clinical outcomes of the patients in the observation group were more favorable. Intraoperative blood loss was lower (105.6 ± 20.8 mL vs 115.3 ± 22.1 mL, P = 0.015), and the incidence of intraoperative adverse events was reduced (5.0% vs 13.3%, P < 0.05).

Postoperatively, patients in the observation group recovered rapidly. Their hospital stay was shorter (8.2 ± 1.2 days vs 9.3 ± 1.4 days, P < 0.001), time to first ambulation occurred earlier (24.6 ± 3.1 hours vs 28.3 ± 3.6 hours, P < 0.001), and time to first anal exhaust was also accelerated (60.7 ± 7.2 hours vs 66.2 ± 8.5 hours, P < 0.001) (Table 6).

Table 6 Comparison of clinical outcome indicators of patients in the two groups.

Group	Intraoperative blood loss (mL)	Postoperative hospital stay (days)	Time to first ambulation (hours)	Time to first anal exhaust (hours)
Observation group (n = 60)	105.6 ± 20.8	8.2 ± 1.2	24.6 ± 3.1	60.7 ± 7.2
Control group (n = 60)	115.3 ± 22.1	9.3 ± 1.4	28.3 ± 3.6	66.2 ± 8.5
t value	2.475	4.619	6.032	3.824
P value	0.015	< 0.001	< 0.001	< 0.001

Comparison of postoperative complication rates between the two groups

The overall postoperative complication rate in the observation group was significantly lower than that in the control group [10.00% (6/60) vs 25.00% (15/60), χ² = 4.675, P = 0.031]. This difference was primarily reflected in lower rates of surgical site infections (3.33% vs 5.00%) and pulmonary infections (1.67% vs 5.00%) in the observation group (Table 7).

Table 7 Comparison of the incidence of complications in patients between the two groups, n (%).

Group	Postoperative fever	Surgical site infection	Anastomotic leak	Pulmonary infection	Intestinal obstruction	Deep vein thrombosis	Total complications
Observation group (n = 60)	2 (3.33)	2 (3.33)	1 (1.67)	1 (1.67)	0 (0.00)	0 (0.00)	6 (10.00)
Control group (n = 60)	4 (6.67)	3 (5.00)	2 (3.33)	3 (5.00)	2 (3.33)	1 (1.67)	15 (25.00)
χ²	-	-	-	-	-	-	4.675
P value	-	-	-	-	-	-	0.031

Comparison of team subjective cognitive load between the two groups

Assessment using the NASA-TLX scale revealed that the SIS model reduced the subjective cognitive load of both surgeons and scrub nurses. In the observation group, the scores for mental demand, temporal demand, effort, and frustration, as well as the total score, were significantly lower than those in the control group (all P < 0.05). Conversely, the performance score, which reflected perceived task accomplishment, was significantly higher in the observation group (P < 0.05) (Figure 1).

Figure 1 Radar chart of NASA Task Load Index scores for subjective cognitive load levels of surgical teams (surgeons and nurses) in both groups. A: NASA Task Load Index (NASA-TLX) workload assessment surgeons; B: NASA-TLX workload assessment operating room nurses. NASA-TLX: NASA Task Load Index.

DISCUSSION

Currently, the concept of modern operating room management is undergoing a transformation from experience-based management to “process-centered” scientific and systematic management. Against this backdrop, standardization has become a core strategy for improving surgical quality and ensuring patient safety[9-11]. As departments within hospitals feature high technology intensity, complex processes, and extremely strict requirements for multidisciplinary collaboration, the operational efficiency and safety of the operating room are directly related to the prognosis of surgical patients.

In operating rooms, the standardized setup of instruments serves as a key entry point for process optimization. Establishing a scientific, unified, and standardized process for instrument placement, handover, and management is conducive to minimizing uncontrollable human factors, making surgical collaboration predictable, repeatable, and efficient[12,13]. As the primary managers and users of surgical instruments, operating room nurses have a deep understanding of the steps of various surgeries, surgeons' preferences, and the characteristics of instruments and thus possess irreplaceable professional advantages and subjective initiative[14-16]. Therefore, it is of great theoretical and practical significance for operating room nurses to take the lead in constructing and implementing a scientific and standardized instrument management model based on practical clinical needs to optimize laparoscopic surgical processes and enhance team collaboration.

The study results showed that, compared with the control group adopting traditional experience-based management, the observation group implementing standardized management exhibited significant advantages in multiple surgical efficiency indicators. In the SIS protocol, from establishing a special task force and decomposing surgical steps, to designing a standardized layout, establishing PSK and SPP, and further formulating systematic training and emergency procedures, all aspects reflect the initiative and professionalism of nursing practice. These findings are consistent with those reported by Pan and Yi[17], who explored the impact of refined management on the surgical efficiency of laparoscopic radical resection for colon cancer. Di Saverio et al[18] conducted in-depth reflections on the process of emergency laparoscopic surgery during the coronavirus disease 2019 pandemic and proposed that standardized algorithmic management is crucial for addressing complex situations.

The operating room occupancy time, surgical preparation time, and core surgical time in the observation group were all significantly shortened (P < 0.05), indicating that the SIS protocol effectively reduced non-value-added time consumption and improved the overall operational efficiency of the operating room by optimizing instrument preparation and handover processes. This result echoes the research conclusions of scholars such as Egan et al[19], who stated that lean management can reduce surgical preparation time to free up nursing time for direct care. Notably, the total number of unplanned intraoperative interruption events, instrument-related interruptions, communication-related interruptions, and the average interruption duration in the observation group were all significantly reduced (P < 0.05), whereas the total number of instrument handovers decreased, the effective handover rate increased, and the average instrument handover time was shortened (P < 0.05).

The SIS protocol emphasizes “process-specific instrument kits” and “predictive preparation”, which changes the traditional serial model of “surgeon’s instruction-nurse’s response”. It fully embodies the application of the “concurrent engineering” concept in surgical processes, realizes the parallel advancement of instrument preparation and surgical progress, and makes “instruments waiting for the surgeon” possible, thereby substantially reducing waiting-related interruptions. Through the combination of a standardized layout (zoned positioning), PSK and SPP, workflow interruptions caused by instrument searching, identification errors, incorrect handover, and communication misunderstandings are significantly reduced, making the surgical process more coherent and stable[20,21]. In their study on the application of the enhanced recovery concept in the nursing of laparoscopic gastrointestinal surgery, Yan et al[22] emphasized that process optimization is the foundation for ensuring a smooth surgery and promoting the early recovery of patients. Through clinical practice, this study further confirmed that a nurse-led SIS is an effective way to achieve this goal.

Meanwhile, the study results showed that in the observation group, intraoperative blood loss, incidence of intraoperative adverse events, postoperative hospital stay, time to first ambulation, time to first anal exhaust/defecation, and overall complication rate were lower than those in the control group (P < 0.05). The improvement in these results is closely related to the inherent benefits of optimizing the surgical process. First, reducing unplanned interruptions and instrument handover delays means less interference with the core steps of surgery, enabling surgeons to perform delicate operations in a more focused and continuous manner, thereby reducing tissue damage and bleeding. Secondly, efficient and accurate instrument collaboration reduces the risk of technical errors caused by incorrect instruments or delays, thereby further reducing the incidence of intraoperative adverse events. Furthermore, a smooth surgical process helps to shorten the duration of anesthesia and surgical stress, which may alleviate the patient's physiological trauma stress response. This is inherently consistent with the findings of Zeng et al[23] regarding perioperative comfort care, which reduced patients' stress responses.

The improvement in postoperative recovery indicators is directly related to the reduction of surgical trauma and stress and conforms to the concept of enhanced recovery after surgery (ERAS). Chen et al[24] showed that ERAS nursing can promote the recovery of gastrointestinal function and improve sleep quality in patients after laparoscopic appendectomy. The results of this study indicate that the standardization of instrument management, as an important optimization in the operating room nursing process, has a positive cascading effect on promoting the postoperative recovery of patients. This can be regarded as a specific manifestation of the process optimization and efficiency improvement principles advocated by ERAS in the context of instrument management. Cao et al[25] also found in their study of elderly patients undergoing laparoscopic total gastrectomy for gastric cancer that implementation of the ERAS protocol can improve patient prognosis.

In addition, the results showed that for surgeons and instrument nurses in the observation group, the scores of the mental demand, temporal demand, effort, and frustration dimensions of the NASA-TLX scale, as well as the total score, were all lower than those in the control group, whereas the score of the performance dimension was higher than that of the control group (P < 0.05). This indicates that standardized management significantly reduces the mental stress and workload of surgical team members. The standardized table layout and PSK model shifted instrument nurses from a passive state of relying on memory and on-site response to an active state of proactive preparation in accordance with predetermined processes. This reduces the dependence on high-intensity working memory and the uncertainty of decision making, thereby lowering the mental load and perceived frustration[26].

Geubbels et al[27] pointed out that simulation training on basic laparoscopic surgical skills could improve the attitudes of operating room nursing students. However, the SIS protocol in this study directly enhanced the work experience and sense of efficacy of in-service nurses by constructing a standardized practical work model. For surgeons, stable and predictable instrument support reduces the time pressure caused by waiting and communication corrections, allowing them to focus more on surgical operations and enhancing their subjective perception of surgical performance. Reduction in team cognitive load and improvement in performance perception are of far-reaching significance for maintaining the morale of the surgical team, reducing occupational burnout, and promoting long-term collaborative rapport[28,29]. Ramzan et al[30] showed that quantitative operating room nursing combined with psychological interventions could improve patients’ stress responses and mental states. The value of this study lies in reducing the factors that cause stress among team members by optimizing the work process itself, further confirming the clinical application advantages of the SIS protocol.

This study has some limitations. First, this was a single-center study with a relatively small sample size (n = 120), which may have limited the statistical power and potentially increased the risk of type II errors. Second, the study population was confined to patients undergoing elective laparoscopic gastrointestinal surgeries (e.g., radical gastrectomy and colorectal cancer surgery), and the conclusions may not be fully generalizable to emergency surgeries, other types of laparoscopic procedures (e.g., hepatobiliary and urological procedures), or open surgeries. Third, the implementation of the SIS protocol was conducted within a specific team and hospital environment, and its effectiveness and feasibility in other institutions with varying resource levels, staff training systems, or cultural contexts warrants further validation through multicenter studies. Future studies should aim to expand the sample size, include diverse surgical types and settings, and employ longer follow-up periods to comprehensively evaluate the long-term impact and broader applicability of the standardized management model.

CONCLUSION

In conclusion, a nurse-led, SIS in the operating room can significantly optimize the laparoscopic gastrointestinal surgery process, reduce ineffective operations and unplanned interruptions, and improve the overall collaborative rapport and work efficiency of the surgical team. These findings support broader clinical implementation of this approach.