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Staying Five Steps Ahead: Keys To Striving For Operating Room Efficiency

At times, I find myself wondering what caused a case that I do routinely to go longer than expected. Was it me? Was it the team? Surely, it must have been anesthesia! According to one study, operating room time costs an estimated $37 per minute.1 Quite literally, when it comes to the operating room, time is money!

I remember one of my mentors in training always saying that if you find yourself regularly taking more than two hours to do routine cases, something needs to change. Now, I should say that this doesn’t include bigger reconstructive cases or cases involving multiple procedures. Speed in the operating room should never be more of a priority than doing good work to ensure your patient has the best possible outcome. After all, this is not a race and I would never advocate treating it as such. However, there is something to be said for operating room efficiency, a point that I try to instill in my residents as well. Accordingly, I have several things I always try to do before and during each case to increase efficiency.

First, prepare for every case before ever getting into the operating room. As obvious as this sounds, this is actually a multifaceted process that includes not just me as the surgeon being ready for the procedure (more on this in a minute) but also includes making sure all the required equipment is present before the patient or I arrive in the room.

Second, make sure you are ready to operate! Doing a case that I do every week is usually more efficient as I have more experience with it and is part of my routine. Conversely, doing less common procedures can drag down my operating time as I am less used to the dissection and steps of the procedure. One can remedy this by not only preparing for the procedure at hand by reading and utilizing resources before the procedure, but also preparing a plan B situation if plan A hits a roadblock. If a reduction method does not go my way after the third or even fourth attempt with one technique, what other way can I achieve the same goal? Taking a step back and not allowing myself to get tunnel vision is so important in these situations and imperative to maintaining efficiency.

Third, I cannot overemphasize the back table and Mayo stand organization. Before I allow the resident or myself to put up the tourniquet, I will ensure the instruments I need are up on the Mayo stand for each step of the procedure and in the order that I will use them. This prevents wasted time going to the back table and asking the scrub tech for each instrument that we need. Now, the scrub tech will still need to handle some equipment but having all instruments organized and ready saves a lot of time.

Fourth is optimal patient positioning to allow for access to the necessary anatomy. As foot and ankle surgeons, our operating field position sometimes changes a few times a day! We may encounter supine, prone, lateral or sloppy lateral all depending on the procedure. I would argue this could easily be at the top of the list as far as knowing when to use which position. I remember so many cases as a resident thinking to myself, this would not be so hard if I was not suturing upside down! Proper positioning can make all the difference in operating room efficiency and appropriate time management.

Lastly, I try to request a team that does foot and ankle procedures or orthopedic cases regularly. While this may not always be possible depending on the operative setting, it can make a huge difference in the flow and efficiency of the case. Nothing is more frustrating than having a team that usually does endoscopy trying to help you do a complex reconstructive case and not being used to the instruments, the sets or power tools that we use.

Any one of the aforementioned tips can individually preserve a few minutes here and there. In the end, they all add up to meaningful time savings. Hopefully, you find these suggestions useful as well.

Dr. Rahnama is a fellowship-trained foot and ankle surgeon and an Assistant Professor at the Georgetown University School of Medicine in Washington, D.C. You can follow him on Instagram @DrAliRahnama for interesting cases and educational material.


1. Childers CP, Maggard-Gibbons M. Understanding costs of care in the operatingroom. JAMA Surg. 2018;153(4):e176233.

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