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Time management in middle ear & mastoid surgery

Time is precious and time is precious. Time is the only commodity which cannot be regained once last. Managing surgical time has many advantages. This presentation describes the advantages of time management during middle ear and mastoid surgeries and describes how to save time during these surgeries.

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Time management in middle ear & mastoid surgery

  1. 1. Dr. Prahlada N.B MBBS, MS(PGI), MBA, MHA Karnataka ENT Hospital & Research Center, Chitradurga
  2. 2. What is time?  Time is capital and not renewable income!  Time and Tide waits for no man!  Time is the only thing which cannot be stretched beyond 24 hours!  Time is the most valuable gift, which can be offered by one to another!  Give time for children, be good parents!  Have time for subordinates good superiors!  We can not make time but surely we can find time.
  3. 3. Advantages of Time Management
  4. 4. Advantages: Surgeon  Time is money  More Consultation time  More surgeries in less time  More time for other academic activities  More time for extra-curricular activities  More time for family!
  5. 5. Advantages: Patient  Economical  Less discomfort  Less chance of operating wound infection  Less anaesthesia risk  Less OT risk  Less hospital stay
  6. 6. Advantages: Hospital  Efficient use of OT Time  Efficient use of OT Staff  Less hospital borne infection rate  Less OT Risk for the patient  Less Hospital stay  More turnover  Economical  Reputation
  7. 7. My average timing!  CM + Tympanoplasty - 26 minutes  MRM + Tympanoplasty - 52 minutes
  8. 8. Why?  Al Shifa Hospital, Perinthalmanna
  9. 9. Why?  Surgical Camps
  10. 10. Why?  MBA  Father of Scientific Management  Frederick Taylor (1856-1915)  Taylorism
  11. 11. Taylorism  Analyzed and synthesized workflows  Improving economic efficiency &  Enhancing labor productivity  Standardization of process steps  Time and motion studies
  12. 12. Surgical Time audit  Recording all events in OT  Classification of events  Analysis of events
  13. 13. Surgical time audit  Recording of all events in OT  Pre-operative  Intra operative  Post-operative
  14. 14. Surgical time audit  Intra-operative events analysis  Divide the steps  When you have large task on hand – divide them into small pieces and perform!  Prepare a Time-audit chart.
  15. 15. Time audit chart Surgical Steps Time in mins. Local Infiltration 3 mins End-aural incision 4 mins Post-aural incision and Harvesting TM Fascia graft 5 mins Tympanomeatal flap elevation 2 mins Denuding the malleus 2 mins Cortical mastoidectomy and canaloplasty 4 mins Check ossicular mobilty & round window reflex 30 secs Check E-tube patency 30 secs Grafting & Stabilizing 3 mins Closure 3 mins Total time taken 28 mins
  16. 16. Surgical time audit  Classification of events  Very important  Not particularly important  Worthless
  17. 17. Surgical time audit  Analysis of events  What is the best of way doing particular task in least possible time?  Can you dedicate more time to high-value steps?  Can you spend less time with low-value steps?  Are there any distractions you can avoid?  Can you modify the technique?  Can you delegate the task?
  18. 18. Surgical time audit Surgical Steps Before Now Local Infiltration 10 3 mins End-aural incision 10 4 mins Post-aural incision and Harvesting TM Fascia graft 20 5 mins Tympanomeatal flap elevation 20 2 mins Denuding the malleus 20 2 mins Cortical mastoidectomy and canaloplasty 30 4 mins Check ossicular mobilty & round window reflex 5 30 secs Check E-tube patency 5 30 secs Grafting & Stabilizing 20 3 mins Closure 20 3 mins Total time taken 2 Hrs 40 mins 28 mins
  19. 19. Factors affecting Surgical time
  20. 20. Patient factors  General physical condition  Risk factors  Type of pathology  Intra-op bleeding
  21. 21. Surgeon factors  Attitude  Training  Philosophy  Planning  Execution  Delegation  Team work
  22. 22. Practice makes man perfect!
  23. 23. SWOT Analysis
  24. 24. TQM – Six Sigma
  25. 25. Anaesthetist  Attitude  Training  Philosophy  Team work
  26. 26. Type anaesthetist  Superficial  Gas Man!  Freelancer
  27. 27. Staff factors  Attitude  Training  Team work
  28. 28. Staff Motivation  Discipline  Participation and involvement  Time management  Morale  Skill development  Communication
  29. 29. Learn the Kaizen way!
  30. 30. Operation theatre  Design  Lighting  Air conditioning
  31. 31. Operation theatre
  32. 32. Equipment  Right equipment  Working equipment  Serviced!  Multi-use
  33. 33. Microscope
  34. 34. Equipment  Micro-instruments – double ended  High speed micro drill  Good burrs  Patent suction tips!  Scissors which cut!
  35. 35. Surgical technique  Plan! Plan! Plan!  Investigate appropriately  Communicate plan to the team  Right surgical technique  Right approach  Right surgical step  Complement surgical steps  Do only what is necessary
  36. 36. Surgical Approach  Transcanal  Endomeatal  End-aural  Post-aural
  37. 37. Surgical Approach  Trans-canal approach  Post-traumatic perforation - < 3 months
  38. 38. Surgical Approach  Endomeatal approach – Wide canal  Post-traumatic perforation - > 3 months  Central perforation – other aetiology  < 3 months.
  39. 39. Surgical Approach  End-aural approach – Narrow Canal  Posterior Central perforation  When Cortical mastoidectomy is not planned
  40. 40. Surgical Approach  End-aural incsions for Koerner’s flap/Post-aural approach  Anterior perforation/Anterior bony overhang  Large perforation/Subtotal/total perofrations  When Cortical mastoidectomy is contemplated  All Cholesteatoma surgery
  41. 41. Cholesteatoma – Decision making  Only Canal wall down  Obliterate when possible  Single stage ossicular reconstruction  Modified Bondy’s mastoidectomy with obliteration  Minimal cholesteatoma  Ossicular chain intact

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