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

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.

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

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”

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

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

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