ORIGINAL ARTICLE

ANZJSurg.com

Optimizing the operating theatre environment

Shing W. Wong, Richard Smith and Phil Crowe

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917..924

Department of Surgery, University of New South Wales, Prince of Wales Hospital, Randwick, New South Wales, Australia

Key words human engineering, operating rooms, operative, outcome assessment, surgical procedures, task performance and analysis. Correspondence Dr Shing Wai Wong, Department of Surgery, Prince of Wales Hospital, Barker Street, Randwick 2031, Australia. Email: sw.wong@unsw.edu.au S. W. Wong FRACS, MS; R. Smith MB BS; P. J. Crowe PhD, FRACS. Accepted for publication 15 June 2010. doi: 10.1111/j.1445-2197.2010.05526.x

Abstract
The operating theatre is a complex place. There are many potential factors which can interfere with surgery and predispose to errors. Optimizing the operating theatre environment can enhance surgeon performance, which can ultimately improve patient outcomes. These factors include the physical environment (such as noise and light), human factors (such as ergonomics), and surgeon-related factors (such as fatigue and stress). As individual factors, they may not affect surgical outcome but in combination, they may exert a signicant inuence. The evidence for some of these working environment factors are examined individually. Optimizing the operating environment may have a potentially more signicant impact on overall surgical outcome than improving individual surgical skill.

Introduction
In 1962, DM Douglas commented that the surgeon looks upon the theatre suite as his workshop in much the same way as the scholar his library, the scientist his laboratory, or the craftsman his bench.1 He proposed that optimizing teamwork, the working environment, and lighting as important requirements for the design of an operating theatre from a surgeons perspective. Surgical outcomes do not just depend on patient factors and surgeon technical skills. External human factors are also important and they include ergonomics, team coordination and leadership, organizational culture, and quality of decision-making.2 Rather than analysing the contribution of individual factors, a systems approach to achieving better surgical outcomes has been advocated. Better outcomes are likely if human error is diminished and surgical safety is maximized. A systems approach to safety associated with surgical operations would involve studying all aspects of the system including the working environment. Reason proposed two methods in analysing human error: the person approach or the system approach.3 The system approach assumes that humans are fallible and that errors are expected. Countermeasures aim to change the working conditions because the human conditions cannot be changed. The Swiss cheese model of system accidents describes alignment of all the holes in each defensive layer (each cheese slice) leading to adverse outcomes. The holes in the defences arise from active failures and latent conditions.
2010 The Authors ANZ Journal of Surgery 2010 Royal Australasian College of Surgeons

Within the operating room, the latent conditions which can be identied and modied can help prevent an adverse event. The environment which surgeons work in has an impact on clinical decision-making during surgery.4 These work environment factors are not beyond the control of surgeons. Optimizing the operating theatre environment can enhance surgeon performance, which can ultimately improve patient outcomes. These factors include the physical environment (such as noise and light), human factors (such as ergonomics), and surgeon-related factors (such as fatigue and stress). As individual factors, they may not affect surgical outcome, but in combination, they may exert a signicant inuence. Many of these factors have not been studied in a real operating theatre environment but have been examined in other work or simulated environments. Nonetheless, these studies can provide us with important insight into how these factors inuence performance. The aim of this paper was to review the evidence for some of these working environment factors.

Lighting
Optimal lighting is required for good vision. Important characteristics of good illumination include strong light, intense area of illumination in the centre, good focus, parallel beams, shadowless, easy manoeuvrability, shielding to prevent glare, and heat reduction (with heat-ltering glass).1,5,6 The overhead lights are the most commonly

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used source of lighting in the operating room. The surgeon or the assistants head may obstruct the light from the light source to the operation eld in deep cavities. One of the disadvantages is that regular adjustment of the overhead operating light may be required and this can increase the risk of contamination and infection. The use of the main and satellite overhead lights together may improve the eld of illumination but different intensities and reections may compromise vision. Use of a headlight has advantages of exibility, control by the surgeon, and vision into deep and narrow spaces.1 Disadvantages of using a headlight include an awkward posture (resulting in neck strain) and limitation of the mobility and visibility of the operating team.7 Flexible bre-optic lights attached to retracting instruments can be used to overcome some of these drawbacks. The light is stronger and better focused when bre-optic light is used in laparoscopic, endoscopic and arthroscopic work. There are drawbacks. Vision can be impaired when the end of the scope is covered by condensation, blood or uid. The light bre-optic bres can be damaged with regular use. One study demonstrated that over 20% of light projected from available light leads had darkened sections (with diminished or absent light transmission).8 There is also a danger of burns when the power of the light source is turned up.9 There are other ways that light can help the surgeon. The use of lighted ureteric stents can aid its identication at laparoscopy.10 The use of different wavelength light can also be benecial to surgeons. Blue-enriched white light in the operating theatre has been used by laparoscopic surgeons to reduce the strain on their eyes from the video monitors. Eye accommodation focuses on wavelengths in the middle of the spectrum, with longer (towards red) wavelengths in virtual focus behind the retina and shorter (towards blue) wavelengths in front of the retina. Less eye accommodation is required to focus short wavelengths on the retina.11 In a study of 94 ofce workers, blue-enriched white light (compared with white light) improved subjective alertness, mood, performance, evening fatigue, concentration and eye discomfort.12 Other studies have also shown an association between increased psychomotor vigilance and reduced sleepiness with exposure to short wavelength light compared with polychromatic light.13,14 Colonoscopic narrow band imaging (NBI) uses short wavelength (blue) endoscopic light to highlight mucosal patterns and microvascular details. NBI can differentiate between colonic neoplastic and non-neoplastic lesions with a sensitivity of 92% and a specicity of 86%.15 Infrared light has been shown to help improve differentiation of the cystic duct and artery, identication of the ureter, and assessment of bowel perfusion by inexperienced laparoscopic surgeons in an animal study.16

articles examining the impact of stress on surgical performance found the key stressors to be laparoscopic surgery, bleeding, distractions, time pressure, procedural complexity and equipment problems.19 In this review, the authors found surgical inexperience and poor coping skills to be associated with greater stress levels and poorer technical performance. Medical staff often downplay the effects of stress.17,20,21 There is emphasis on leadership and self-condence in the surgical community and stress is often perceived as a sign of failure.22 A survey of 167 consultant surgeons from 10 hospitals indicated that 82% believed that they can leave personal problems behind when working.20 Seventy-six percent of surgeons believed that their decisionmaking ability was as good in emergency situations as in routine situations. This has not been well studied. One study demonstrated a higher incidence of errors during simulated laparoscopic surgery under the condition of mental stress with a simple mathematical task.23 Surgeons may acquire attributes and skills that facilitate performance under pressure. These skills relate to preparation, experience, personal emotional control, environmental control, focusing on the big picture, maintaining and restoring order, and maintaining condence and composure.21 Negative stress coping strategies used by novice surgeons were shown to correlate with poor technical performances.24 These negative strategies were escape, rumination, resignation, self-blame, avoidance and need for social support. One study found effective coping strategies to be signicantly related to surgical performance during simulated carotid endarterectomy surgery.25 The authors assessment of surgical coping skills was based on six variables: preventive coping (plan and check to avoid stressors), anticipatory coping (reduce inevitable stressors), proactive coping (enhance personal resources), intraoperative control of self, intraoperative control of the situation, and control of the overall operative situation. Surgeons stress levels were assessed by the validated State-Trait-Anxiety-Inventory score, surgical assistant rating, heart rate and variability, and salivary cortisol levels. Experience was the strongest predictor of performance. Overall, high coping skills and low stress levels both enhanced surgical performance. However, coping skills were not related to both the stress responses and experience. The authors suggested that these surgical coping strategies should be taught because they are not automatically acquired with clinical experience. Interestingly, low stress levels in inexperienced surgeons worsened performance, possibly related to lack of insight and overcondence.

Gowns and gloves

Important considerations for gowns and gloves include the potentially conicting characteristics of protection and comfort. The need for a gown to be liquid repellent and to protect the wearer is a priority. Woven cotton (also known as muslin) is an acceptable barrier when dry but loses its barrier capabilities when wet.26 One study indicated that four of ve non-woven fabrics from disposable gowns were effective barriers against the transmission of bacteria in a laboratory setting, but all three woven fabric from reusable gowns allowed some transmission of bacteria.27 Laundering has also been
2010 The Authors ANZ Journal of Surgery 2010 Royal Australasian College of Surgeons

Stress and coping

Stress can facilitate performance by enhancing alertness, concentration, focus and efciency of action as long as the stress level does not exceed coping skills. High levels of stress can impair technical skills and non-technical skills such as judgment, decision-making and communication.17 An observational study of 55 surgical operations found technical, patient and equipment problems to be the most stressful factors in the operating room.18 A systemic review of 22

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shown to reduce the ability of the fabric of reusable gowns to prevent the transmission of bacteria in an in vitro setting.28 Whilst much attention has been paid to the investigation of which gowns offer better protection to surgeon and patient from contamination, little research has focussed on which gowns are more comfortable. One study showed that reusable gowns had a blood contamination rate of 90% compared with 11% for single layer disposable gowns and 3% for reinforced disposable gowns.29 In this study, the majority of surgeons felt comfortable and safe in the disposable gowns, compared with the minority of surgeons in the reusable gowns. A simulated operating theatre study revealed the overall comfort of reusable and disposable gowns to be equivalent despite the higher thermal insulation of the latter.30 The amount of sweating was less with disposable gowns compared with reusable gowns. Reusable cotton gowns were subjectively hotter than disposable non-woven gowns. The benets of double gloving in preventing perforation have been well documented by a Cochrane review.31 Furthermore, they showed that triple gloving, knitted outer gloves, and glove liners also reduce perforations, and that indicator systems (with a different colour glove inside to indicate outer perforation) result in signicantly more perforations being detected during surgery. However, this was not related to a signicant reduction in surgical site infections. The drawback of double gloving includes constriction of the hands and ngers which can lead to discomfort and paraesthesiae. The use of a larger inner glove may mitigate this tightness of t. The evidence for the inuence of double gloving on performance is conicting. One study found no signicant difference in 2-point discrimination and number of knots tied in 60 s, with both single and double gloves.32 Another study found no signicant impairment in 2-point discrimination or manual dexterity (assessed by pegboard assembly) with double gloves compared with single or no gloves in 53 subjects.33 However, this study was funded by the glove manufacturers. Conversely, other studies have found double gloving to signicantly impair surgeons perception of comfort, sensitivity and dexterity.34,35 Supplemental hand protection systems such as puncture resistant gloves, nger guards and glove liners protect against needle puncture but signicantly reduces cutaneous sensibility.36 In this study, the authors also found that cutaneous sensibility was similar between the normal latex gloves and the thicker latex gloves.

For speech noise to be clearly understood, it needs to be 10 dB above the ambient noise level. A relaxed-to-raised vocal effort is up to 66 dB and therefore ambient noise in the operating room should be kept to below 56 dB. The mean noise level of an operating theatre in one study was above this recommendation at 58 dB.40 One laboratory study indicated that speech understanding was impacted negatively by background dental ofce noise but not by the presence of a surgical mask.41 The effect of noise on surgical performance may depend on the complexity of the task and the experience of the surgeon. In two separate papers, the same group found contradictory results on the effect of background noise at 8085 dB on laparoscopic performance in a laboratory setting.23,42 One study found background noise impaired dexterity and signicantly increased the incidence of errors while the other study found no impact of noise on the performance of a complex laparoscopic task. Time, number of movements, total path length, global score, accuracy and knot quality did not change with the condition of loud background noise. The former study involved a simpler laparoscopic transfer task and the latter study involved a more complex task of laparoscopic suturing. The authors postulated that the higher levels of concentration required with the more difcult task may allow surgeons to block out the noise. Another laboratory-based study found that pre-recorded noise from an actual operating room (5090 dB) worsened robot-assisted laparoscopic performance by medical students.43 These authors found a greater detrimental inuence of noise on more difcult tasks. The level of noise and the type of noise (random versus continuous) are other noise variables which need to be considered when analysing their effect on surgical performance.

Music
It has been postulated that appropriate use of music in the operating theatre can reduce stress and improve staff performance.44 Music has been shown to reduce surgeon stress and enhance surgical performance in a laboratory setting.45 Autonomic cardiovascular reactivity was signicantly less and speed and accuracy of task performance was signicantly better with background music. Surgeon-selected music resulted in signicantly better results than experimenterselected music, which was better than no music. However, the 50 male surgeons involved in the study were volunteers who normally listen to music during their surgery. This selection bias could partially explain the favourable results of the study. In contrast, laparoscopic surgical performance was unaffected by background classical music in a study of 12 surgeons of varying experience.42 A randomized controlled trial of 45 novice laparoscopic surgeons found a detrimental effect of activating music on surgical performance accompanied by a signicantly increased autonomic response (heart rate).46 The effect of music on performance may be related to the experience of the surgeon. Familiar music has been shown to signicantly increase the heart rate and increase detections in a vigilance task, as well as decrease vigilance decrement over time.47 The type of music did not seem to have a signicant effect. In another study, subjects spatial task performances were noted to be enhanced by a Mozart sonata

Noise
Noise is a potential problem for concentration and communication in operating theatres. Studies have found highest noise levels during orthopaedic and neurosurgical procedures.37,38 The loudest noises tended to be recorded during the preparation period: a dropped steel bowl measured 108 decibels (dB); gas escaping a pneumatic wall outlet measured 98 dB; and raising trolley sides measured 85 dB.39 Normal speech between staff measured 60 dB. During surgery, the background noise tended to be much less, with the sucker and ventilator the main sources of continuous noise. Sound levels only exceeded the moderate range (6080 dB) for 1% of the time. However, it was these uncontrollable, unpredictable noises which produce a startle response, and can interfere with the performance of complex tasks.
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compared with listening to relaxation tape and silent conditions.48 The spatial IQ scores were 119, 111 and 110 for the three conditions, respectively. The inuence of music on patient comfort and anaesthetist performance should also be taken into account when considering whether music should be played in the operating theatre. Studies have indicated a potential anxiolytic, analgesic and sedative benet of music.4953 A survey of 144 anaesthetists found that one quarter felt that music reduced their vigilance and impaired their communication with other staff.54 A study of 12 anaesthetic trainees found no signicant difference in psychomotor performance (testing numeric vigilance, tracking and reaction time) under four conditions (classical music, self-chosen music, white noise and silence).55 The 24 non-anaesthetist participants in another study were able to judge trends in simulated patient monitoring more accurately while listening to music.56 Despite this nding, participants reported a preference to work in silence.

Interruptions
A high frequency of distractions and interruptions occur in the operating theatre and they can affect surgeon concentration. A Disruptions in Surgery Index has been proposed by one group.57 They classied surgical disruptions into seven domains: individuals skill, performance and personality; operating room environment; communication; coordination and situational awareness; patient-related disruptions; team cohesion; and organizational disruptions. The overall disruptions rate was reported to be 25% by surgeons, 37% by anaesthetists, and 42% by nurses. Distractions from case-irrelevant communications have been studied.58 Visitors to the operating room provided most of these distractions. Those addressed to the surgeons were less distracting to the theatre team than those directed to the nurse or anaesthetist. The inconsequential background conversations (small talk) may help reduce stress and tensions of the operating team but may also be more distracting than quieter, non discernable noise for a surgical team.39

Theatre temperature is another factor to consider. Some anaesthetists like to turn up the ambient operating room temperature to help achieve normothermia. This may reduce surgeon comfort levels and impact on their performance. Whilst it is crucial to set the temperature that best suits the patient, one must also consider the theatre staff. A recent survey of medical students in Britain found that 12% of respondents had suffered a near or actual syncopal episode in theatre; of these, 79% reported hot temperature as a contributing factor.65 One study of call centre operators found a signicant reduction in performance when the temperature was increased from 22.5 to 24.5C.66 Moderate heat stress has also been shown to effect mental performance by lowering levels of arousal.67 Surgeons prefer an ambient temperature of 1921C and a relative humidity of 4555%.1,68 To counter for the operating light, a temperature of 18 has been recommended. This was 2.5 lower than the preferred average of other staff. It was likely a coincidence, the authors suggested, that the average recorded temperature usually controlled by the anaesthetist was much closer to their preferred temperature of 21.5! Cooling vests based on those worn by remen and adapted to the surgical environment have been trialled in a non-clinical setting.69 The preliminary tests found an increase in the comfort of the surgeon, with measurable benets in terms of lower skin temperature and sweat rates.

Posture
Fatigue during surgery can be reduced with better posture. Poor posture has been shown to impair psychomotor performance.70,71 Discomfort and higher postural shift rate have been shown to have an adverse effect on the error rate. Open surgical procedures usually require prolonged standing with occasional awkward body positions. Studies have indicated that general surgeons experience substantial stress to their shoulders, neck and back with their postures during surgery.72,73 Compared with ENT surgeons, general surgeons have their backs in bent or/and twisted positions more often, stood on one leg more often, and sat down less often. Laparoscopic surgery can result in more postural fatigue than open surgery because it is accompanied by a more upright posture, as well as less body movement and weight shifting.74 It has been suggested that adopting a sitting position during part of the operation may reduce torso fatigue during extended periods of light manipulative work. However, a study looking at the kinematics of motion performed in sitting and standing positions reported comparable asymmetry in lumbar lateral exion and thoracic movement.75 Pelvic asymmetry contributes to musculoskeletal pain by altering the body dynamics with compensation by spinal movement. These compensatory trunk movements were not corrected by levelling the pelvis while sitting. One of the problems with sitting during operations is the lack of leg space under the operating table. This is associated with a forward leaning posture, which is a signicant risk factor for back pain. Working while seated has advantages of improved precision and stability, less total body energy consumption and allowing free movements of the leg. In a simulated setting of poor leg space, the trunk posture during standing, supported-standing (riding on a high saddle chair) and sitting were examined in a Danish study.76 The
2010 The Authors ANZ Journal of Surgery 2010 Royal Australasian College of Surgeons

Theatre temperature
The temperature of an operating theatre is often determined by the anaesthetist, with due consideration to the needs of the patient, balanced against his/her own comfort as well as that of the entire theatre staff. Maintaining normothermia for the patient is of paramount importance for many reasons. Hypothermia is dened as core temperature below 36 degrees, and is commonly caused in surgery by exposure to the cold operating room environment, evaporation of skin sterilizing solutions and impairment of thermoregulation by anaesthesia.59 Prospective randomized trials have demonstrated a relationship between hypothermia and increased intraoperative blood loss, cardiac events and surgical wound infections.60,61 Methods of directly heating the patient; such as forced air warming systems, heated mattresses and warmed intravenous uid infusion; have been shown to prevent hypothermia and improve surgical outcomes.60,6264

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authors found the saddle chair position to be associated with a more intermediate lumbar spine position less kyphotic than sitting and less lordotic than standing. The cervical spine was also less exed than with standing. However, the arms are raised more forward. Elevation of the arms to above 45 has been shown to increase the risk of shoulder and neck pain. The authors recommended alternating between the standing and the supported-standing positions to avoid any prolonged specic posture. The working height of the operating table has different impact on individual muscle load. The static muscular load on the trapezius muscle has been shown to be above recommended threshold levels in the standing position when the table was over 5 cm above the elbow level.76 In the absence of forearm support, the authors recommended the working level to be adjusted to less than 5 cm above elbow level. The use of armrests in simulated laparoscopic surgery has been shown to reduce error rates and discomfort signicantly.77

Regular theatre staff

The assistance of regular experienced nursing scrub staff and assistant should reduce stress levels and result in better co-ordination for the procedure. The benets of an experienced or dedicated team have been shown. Ideally, the surgeon has to say little and the instruments ow from the sisters hand to the surgeons without orders.1 One observational study found that experienced scrub nurses spent shorter amount of the operation time watching surgery but performed more anticipatory movements when compared with intermediate skill nurses.78 Another study reported decreased operating times and reduced conversion rates for laparoscopic cholecystectomy operations with a dedicated trained nursing team.79 This study was a retrospective study and the operations were performed in two separate hospitals. The benet may relate to the system as a whole rather than just because of a dedicated team. Non-technical skills of the operating theatre staff are as important as technical skills in achieving safe and efcient practice. These non-technical skills include communication, situation awareness, decision-making, leadership, stress and fatigue management, and critique.80 Poor communication between team members has been recognized as a contributing factor for some adverse events. Another factor which impedes good communication in the operating theatre is the hierarchical structure.81 Encouraging a non-threatening environment where theatre staff members can speak up has the potential to improve the operating theatre efciency and to reduce error. Stable theatre nurse teams have been shown to enable advanced planning and promote safety.82 Data collected from interviewing operating room nurses found factors which potentially lead to errors in teamwork included constant turnover of teams, overtime work (which hindered concentration and condence) and individual emotional distress. Another study found a higher complication rate in a cataract theatre when there was unplanned leave and replacement of regular staff by temporary staff.83 However, the authors found no relationship between the experience of the scrub nurse and complication rates. They attributed the higher complication rate to stress related to the individual being moved unexpectantly or to the changed dynamics of the team. The study was limited by being a retrospective case-control study. Inevitably, team members may
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change unexpectedly but stress associated with changed team dynamics can be reduced by ensuring that all members of the surgical team are at least introduced to one another, as should now happen with the surgical timeout checklist. The presence of trainees, either as the operating surgeon or assistant surgeon will also have an impact on the surgical procedures. A regular experienced trainee can improve the ow of surgery by anticipating the habitual requirements and movements of the operating surgeon. Studies have shown the presence of trainees during major operations do not compromise a good outcome, even if they are the primary surgeon as long as they are supervised.84,85 Trainee participation enhances their surgical training. On the other hand, trainee surgeons take longer to perform operations and this may increase stress levels by the need to complete a surgical list within an allotted time period. One study found a signicant relationship between the incidence of operative errors and time pressure.23 This has been identied as a factor which negatively imparts on the trainees educational experience in the operating room and is likely to affect his/her surgical performance. A recent study has also shown that the relationship of the trainee with the consultant surgeon is a major factor affecting the learning climate of the operating room.86 An interesting nding from a multi-centre trial found that the duration of surgery for a total hip replacement was signicantly reduced (by 28 min) when the assistant was a surgeons assistant rather than a trainee.87 Presumably, the operation is more efcient because the experienced assistant can anticipate the requirements and operative steps of the surgeon. A robotic assistant is the other extreme. It offers the advantages of more efciency (by remembering the exact preferences of the surgeon), less potential tension with the assistant, more precision and less tremor, better ergonomics, no fatigability and less retraction forces.8890 The disadvantages include one less pair of eyes, no dynamic movements and less adaptability.

Fatigue
Human performance have been shown to be impaired by shift work, circadian rhythm disturbances and fatigue from prolonged work hours.91,92 Studies have shown that fatigue impairs human performance in a laboratory setting, worsens psychomotor performance and emotions, and perhaps clinical performance.93,94 However, many of these studies had methodological aws and failed to control for circadian effects. Surgeons may be at increased risk of making errors when sleep deprived. One matched retrospective cohort study reported no signicantly increased morbidity with procedures performed the day after surgeons worked overnight (between midnight and 6.00 hours).95 However, there was an increased morbidity for surgery performed the day after surgeons worked overnight if sleep opportunities were less than 6 h (6.2% versus 3.4%). Studies examining the effect of fatigue on simulated laparoscopic task performance have demonstrated conicting results, probably related to methodological aws.96 A meta-analysis showed mood to be more affected by sleep deprivation than cognitive or motor performance (in that order).97 Other studies examining the effect of fatigue on overall surgical prociency have also showed cognitive performance to be more

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impaired than psychomotor skills.98,99 In the post-call condition, surgeons made 25% fewer cognitive errors than residents but psychomotor skills were equally affected in both groups. These studies suggest that there should be a greater emphasis in preventing cognitive errors during times of fatigue.

Time of surgery
Shift work disrupts the circadian rhythm and may affect other physiological systems. Studies have shown a decline in mental performance and decision-making during the hours of midnight and 6.00 hours.94,100 Alertness and performance have a rhythmicity with a maximum in the late afternoon and a minimum around 5.00 hours. Tasks related to gross motor performance such as strength are better performed in the evening than the morning and ner motor coordination tasks are better performed in the morning.101 The morning superiority of the latter tasks has been attributed to a lower circadian arousal level and less inuence of fatigue. The risk of airline pilot error was increased by almost 50% during the period of the early morning (24.00 to 6.00 hours) in one study.102 This was attributed to attention problems and fatigue. Anaesthetic studies have reported a higher rate of adverse effects for procedures starting in the afternoon or night.103,104 Surgical studies have not reported this association. There was no relationship between the timing and outcome of elective coronary artery bypass graft surgery.105 Perioperative risk was not affected by surgical start time, day of the week or months when new residents started. In this study, only elective cases were studied and most were performed during daylight hours and therefore the effect of the circadian rhythm were not well analysed. Another retrospective study also found no relationship between surgical complications and the time of day for cadaveric kidney transplants.106 Prolonged surgical workload and reduced mental energy may inuence surgical performance during different times of the day. The time of day which laparoscopic-assisted vaginal hysterectomy was performed did not inuence surgical outcomes in a retrospective study.107 Paradoxically, the authors found a shorter mean operating time when cases started in the afternoon compared with rst morning cases. This was attributed to improved prociency with practice during the day.

factors. The teaching of non-technical skills such as stress management and crisis training would prepare surgeons for the complex demands of the operating environment. Trainees can receive training and feedback in a safe environment of a simulated operating theatre. Surgeons should consider examining their own surgical environment and then attempt to identify factors that they can control. By enhancing these factors, not only may surgical outcomes be improved but also satisfaction with the surgical workplace. As surgeons, we have a responsibility to our patients to optimize the environment in which they will be operated in.

References
1. Douglas DM. Operating-theatre design. Lancet 1962; 2: 1639. 2. Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW. Systems approaches to surgical quality and safety. Ann. Surg. 2004; 239: 475 82. 3. Reason J. Human errors: models and management. Br. Med. J. 2000; 320: 76870. 4. Francis DMA. Surgical decision making. ANZ J. Surg. 2009; 79: 886 91. 5. Dawson-Edwards P. Auxiliary overhead spot-light. Lancet 1957; 270: 5256. 6. Browne D. A headlight for general surgery. Lancet 1956; 267: 191. 7. Okoro SA, Patel TH, Wang PT. Who needs the surgical headlight. Cleft Palate Craniofac. J. 2007; 44: 1268. 8. Drury NE, Pollard R, Dyer JP. Minimally invasive surgery: only as good as the picture. Ann. R. Coll. Surg. Engl. 2004; 86: 401. 9. Bellina JH, Haas M. Cold light sources. Are they really cold. J. Reprod. Med. 1984; 29: 2757. 10. Chahin F, Dwivedi AJ, Paramesh A et al. The implications of lighted ureteral stenting in laparoscopic colectomy. JSLS 2002; 6: 4952. 11. Richter HO, Knez I. Superior short-wavelength contrast sensitivity in asthenopics during reexive readjustments of ocular accommodation. Ophthalmic. Physiol. Opt. 2007; 27: 36172. 12. Viola AU, James LM, Schlangen LJ, Dijk DJ. Blue-enriched white light in the workplace improves self-reported alertness, performance and sleep quality. Scand. J. Work Environ. Health 2008; 34: 297306. 13. Cajochen C, Munch M, Kobialka S et al. High sensitivity of human melatonin, alertness, thermoregulation, and heart rate to short wavelength light. J. Clin. Endocrinol. Metab. 2005; 90: 13116. 14. Lockley SW, Evans EE, Schleer FA et al. Short-wavelength sensitivity for the direct effects of light on alertness, vigilance, and the waking electroencephalogram in humans. Sleep 2006; 29: 1618. 15. Van Den Broek FJ, Reitsma JB, Curvers WL, Fockens P, Dekker E. Systematic review of narrow-band imaging for the detection and differentiation of neoplastic and nonneoplastic lesions in the colon. Gastrointest. Endosc. 2009; 69: 12435. 16. Roberts WW, Dinkel TA, Schulam PG, Bonnell L, Kavoussi LR. Laparoscopic infrared imaging. Surg. Endosc. 1997; 11: 12213. 17. Wetzel CM, Kneebone RL, Woloshynowych M et al. The effects of stress on surgical performance. Am. J. Surg. 2006; 191: 510. 18. Arora S, Hull L, Sevdalis N et al. Factors compromising safety in surgery: stressful events in the operating room. Am. J. Surg. 2010; 199: 605. 19. Arora S, Sevdalis N, Nestel D, Woloshynowych M, Darzi A, Kneebone R. The impact of stress on surgical performance: a systematic review of the literature. Surgery 2010; 147: 31830. 20. Sexton JB, Thomas E, Helmreich R. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000; 320: 7459.

Conclusions
The operating theatre is a complex system. Most operations are performed efciently and safely despite the potential for interference and errors from different sources. Optimizing the operating environment to make the surgeon more comfortable will improve safety and quality. Certain environmental factors can be controlled. Some stressors such as noise, outside inuences and interruptions can be reduced by altering operating room practices. Maintaining the same operating team, more thoughtful scheduling/planning of cases and better preparation with a good nights rest are some of the methods that can be used to improve outcomes. The surgeon should also consider the needs of the patient, anaesthetist and other theatre staff with the variables of temperature and music. More emphasis and consideration should be placed on posture and other ergonomic

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