Overlapping Surgery in Plastic Surgery

An Analysis of Patient Safety and Clinical Outcomes

Rajiv P. Parikh, M.D., M.P.H.S.; Ketan Sharma, M.D., M.P.H.; Melissa Thornton, B.S.; Gabriella Brown, B.S.; Terence M. Myckatyn, M.D.


Plast Reconstr Surg. 2019;143(6):1787-1796. 

In This Article

Patients and Methods

Study Design and Population

This study is a retrospective cohort analysis of a prospectively maintained database of consecutive patients undergoing plastic surgery operations at Barnes-Jewish Hospital/Washington University in St. Louis School of Medicine over a 2-year period from January 1, 2016, through January 1, 2018. All cases were performed by a single full-time surgeon with a broad scope of practice. Patients were eligible for inclusion if they underwent a scheduled inpatient or outpatient procedure in the operating room, had at least 90-days of follow-up, and had complete data available. Patients were excluded from analysis if they underwent an emergent operation and/or had an office-based procedure.

Overlapping Surgery and Institutional Policies

Two primary cohorts were identified: patients undergoing overlapping surgical procedures and patients undergoing nonoverlapping surgical procedures. Overlapping surgery was defined as an operation in which any part of the surgical procedure for which the primary attending surgeon was responsible coincided with another operation for which the same primary attending surgeon was performing. This definition is consistent with prior studies and the American Society of Plastic Surgeons policy statement, which defines overlapping surgery as: "surgeries in which part or all of the procedures chronologically coincide and when the patient's care is left with another qualified medical provider."[6] In overlapping surgery, the primary attending surgeon is present for critical portions of the procedure (as determined by the attending surgeon) and is immediately available if asked to return to the operating room. At our institution, and consistent with American Society of Plastic Surgeons and American College of Surgeons policy recommendations, the practice of concurrent surgery is prohibited.[5,6]

Patient and Clinical Factors

Operative case times, including the total duration (from the time the patient entered the room to the time the patient exited the room), total operative duration (time from skin incision and/or index procedure start to procedure completion with surgical-site closure and/or dressing application), and total anesthesia duration (time when anesthesia provider first assumed care preoperatively to time care was transferred to the postoperative acute care unit providers) were documented. If any part of the operative duration overlapped, the surgery was considered overlapping. The total time of overlap was recorded for all overlapping cases. In addition, for combined cases, defined as surgical procedures requiring two primary attending surgeons with different specialty training, the procedure start time for a case to be considered overlapping was recorded as the time the plastic surgery attending physician first scrubbed and started the plastic surgery aspects. For example, in immediate breast reconstruction cases, an operation was only considered overlapping if the procedure time for the breast reconstruction portion, and not the mastectomy portion, of the case overlapped with the procedure time of a separate operation for which the plastic surgery attending physician was responsible.

Patient demographic and clinical data, including American Society of Anesthesiologists physical status classification, age, sex, body mass index, patient comorbidities, smoking status, laterality (unilateral versus bilateral) of procedure, procedure subspecialty category (breast reconstruction, aesthetic surgery, or general reconstructive surgery), and specific procedure performed were recorded. To appropriately account for baseline burden of disease and case mix, we used the updated Charlson Comorbidity Index, as described by Quan et al., and tabulated scores for each patient.[10]

Outcomes of Interest

The primary outcome of interest was postoperative complications within 90 days. Additional clinical outcomes of interest included unplanned reoperations within 90 days, unplanned readmissions within 30 days, emergency room visits within 30 days, total operative duration, and Agency for Healthcare Research and Quality patient safety indicators for relevant potential adverse events within 90 days, including Patient Safety Indicator 04, death rate among surgical inpatients; Patient Safety Indicator 05, retained surgical item; Patient Safety Indicator 10, postoperative physiologic and metabolic derangement rate; Patient Safety Indicator 11, postoperative respiratory failure rate; Patient Safety Indicator 12, pulmonary embolism or deep vein thrombosis rate; and Patient Safety Indicator 13, postoperative sepsis rate.[11]

Statistical Analyses

Statistical analyses were performed using established methods and SAS software (Version 9.4; SAS Institute Inc., Cary, N.C.). Summary statistics were described using established methods. Continuous variables of interest were compared by means of Wilcoxon rank sum test, whereas categorical variables were compared using chi-square analyses or Fisher's exact test. To analyze the relationship between amount of overlapping duration on postoperative complication rates, a bivariate logistic regression was performed. A power analysis was performed a priori to estimate an appropriate sample size based on the primary outcome of postoperative complication rate. Using a two-sample, two-proportion test, with a baseline rate of 12 percent in nonoverlapping groups (from preliminary data), a noninferiority margin of 5 percent, and a sampling ratio of 1, at least 310 subjects would be required per group. Alpha = 0.05 indicated significance in all tests.