Department of Bio-Surgery and Surgical Technology, Imperial College, London, UK.
Surgery. 2010 Mar;147(3):318-30, 330.e1-6. doi: 10.1016/j.surg.2009.10.007. Epub 2009 Dec 14.
Safe surgical practice requires a combination of technical and nontechnical abilities. Both sets of skills can be impaired by intra-operative stress, compromising performance and patient safety. This systematic review aims to assess the effects of intra-operative stress on surgical performance.
A systematic search strategy was implemented to obtain relevant articles. MEDLINE, EMBASE, and PsycINFO databases were searched, and 3,547 abstracts were identified. After application of limits, 660 abstracts were retrieved for subsequent evaluation. Studies were included on the basis of predetermined inclusion criteria and independent assessment by 2 reviewers.
In all, 22 articles formed the evidence base for this review. Key stressors included laparoscopic surgery (7 studies), bleeding (4 studies), distractions (4 studies), time pressure (3 studies), procedural complexity (3 studies), and equipment problems (2 studies). The methods for assessing stress and performance varied greatly across studies, rendering cross-study comparisons difficult. With only 7 studies assessing stress and surgical performance concurrently, establishing a direct link was challenging. Despite this shortfall, the direction of the evidence suggested that excessive stress impairs performance. Specifically, laparoscopic procedures trigger greater stress levels and poorer technical performance (3 studies), and expert surgeons experience less stress and less impaired performance compared with juniors (2 studies). Finally, 3 studies suggest that stressful crises impair surgeons' nontechnical skills (eg, communication and decision making).
Surgeons are subject to many intra-operative stressors that can impair their performance. Current evidence is characterized by marked heterogeneity of research designs and variable study quality. Further research on stress and performance is required so that surgical training and clinical excellence can flourish.
安全的外科手术需要技术和非技术能力的结合。这两套技能都可能因术中压力而受损，从而影响手术表现和患者安全。本系统评价旨在评估术中压力对手术表现的影响。
实施了系统搜索策略以获取相关文章。检索了 MEDLINE、EMBASE 和 PsycINFO 数据库，并确定了 3547 篇摘要。应用限制后，检索了 660 篇摘要进行后续评估。根据预定的纳入标准和 2 位评审员的独立评估，纳入研究。
共有 22 篇文章构成了本综述的证据基础。主要压力源包括腹腔镜手术（7 项研究）、出血（4 项研究）、干扰（4 项研究）、时间压力（3 项研究）、程序复杂性（3 项研究）和设备问题（2 项研究）。评估压力和表现的方法在研究之间差异很大，使得跨研究比较变得困难。只有 7 项研究同时评估了压力和手术表现，因此难以建立直接联系。尽管存在这种缺陷，但证据的方向表明，过度的压力会损害表现。具体来说，腹腔镜手术会引发更高的压力水平和更差的技术表现（3 项研究），与新手相比，专家外科医生经历的压力较小，表现受损也较小（2 项研究）。最后，有 3 项研究表明，压力危机会损害外科医生的非技术技能（例如沟通和决策能力）。
外科医生会受到许多术中压力源的影响，这些压力源会损害他们的表现。目前的证据以研究设计的明显异质性和可变的研究质量为特征。需要进一步研究压力和表现，以促进外科培训和临床卓越的发展。
