From the Department of Plastic Surgery, University of Texas Southwestern Medical Center.
Plast Reconstr Surg. 2023 Nov 1;152(5):791e-800e. doi: 10.1097/PRS.0000000000010379. Epub 2023 Mar 8.
Deep inferior epigastric perforator (DIEP) flaps are nuanced, multistep, complex procedures. Recent studies have hinted that operational flow can be a sensitive barometer for safety, efficiency, and overall outcomes. The authors critically assess the utility of implementing deliberate practice and process mapping as a research tool in the context of morbidity and operative time.
Co-surgeons at a university hospital implemented deliberate practice and performed two prospective process analysis studies evaluating critical steps in DIEP flap reconstruction. During the 9-month period (June of 2018 to February of 2019), the flap harvest and microsurgery steps were assessed. During the 8-month period (January to August of 2020), the analysis was expanded to encompass the entire operation. To evaluate the immediate and sustained impact of process analysis, 375 bilateral DIEP flap patients were divided into eight consecutive 9-month intervals completed before, during, and after the two studies. Using risk-adjusted multivariate regressions, morbidity and operative time were compared between groups.
Time intervals completed before the first study had comparable morbidity and operative time. During the first study, there was an immediate 83.8% ( P < 0.001) decreased risk in morbidity. Operative time during the second study decreased by 2.19 hours ( P < 0.001). Morbidity and operative time continued to decrease until the end of data collection [62.1% decreased risk in morbidity ( P = 0.023) and decreased operative time of 2.22 hours ( P < 0.001)].
Deliberate practice and process analysis are powerful tools. Implementation of these tools can generate immediate and sustained decreases in morbidity and operative time for patients undergoing procedures such as DIEP flap breast reconstruction.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
深部腹壁下动脉穿支皮瓣（DIEP）是一种精细、多步骤、复杂的手术。最近的研究表明，手术流程可以作为衡量安全性、效率和整体结果的敏感指标。作者批判性地评估了在发病率和手术时间方面实施刻意练习和流程映射作为研究工具的效用。
在一家大学医院，共同手术者实施了刻意练习，并进行了两项前瞻性流程分析研究，评估了 DIEP 皮瓣重建的关键步骤。在 9 个月的时间（2018 年 6 月至 2019 年 2 月）内，评估了皮瓣采集和显微外科步骤。在 8 个月的时间（2020 年 1 月至 8 月）内，分析扩展到涵盖整个手术。为了评估流程分析的即时和持续影响，将 375 例双侧 DIEP 皮瓣患者分为在两项研究之前、期间和之后完成的连续 8 个 9 个月的间隔。使用风险调整后的多元回归，比较组间发病率和手术时间。
在第一次研究之前完成的时间间隔，发病率和手术时间相当。在第一次研究期间，发病率的风险降低了 83.8%（P < 0.001）。第二次研究期间的手术时间减少了 2.19 小时（P < 0.001）。发病率和手术时间持续下降，直到数据收集结束[发病率风险降低 62.1%（P = 0.023）和手术时间减少 2.22 小时（P < 0.001）]。
刻意练习和流程分析是强大的工具。这些工具的实施可以为接受 DIEP 皮瓣乳房重建等手术的患者带来即时和持续的发病率和手术时间降低。
临床问题/证据水平：治疗性，III 级。
