Table 2.

Implemented and evaluated interventions

Reference	Intervention category	Intervention details	Intervention implementation	Target team members	Outcome measures	Outcome of intervention	Intervention challenges
Franasiak [41]	Training	Training on ergonomic modifications to the console workstation and posture	Training implemented over 6 months	Surgeons (n = 32)	Ergonomic strain (measured pre/post intervention)—evaluated using Nordic Musculoskeletal Questionnaire (NMQ)	All surgeons found training to be helpful, and 88% (28/32) changed their practice as a result of the training. Of 19 surgeons who reported strain in the original survey, 14 (74%) noted a decrease in strain after training	Reports of strain are subjective
Jing [33]	Checklist	Implementation of a checklist to improve pre-procedure preparation for robotic-assisted prostatectomies and improve safety and efficiency	Use of checklist in 22 robotic-assisted radical prostatectomy procedures over a two-month trial period	OR staff	Focus group feedback (after trial period)	OR staff felt more confident, felt more aware of what was needed when setting up and reported that the surgery was smoother and that there were fewer interruptions because participants were less likely to leave the OR to retrieve a surgical item	n/a
McCarroll [34]	Checklist	Implementation of a computerized checklist for robotic-assisted surgery. Developed based of the World Health Organization’s Safe Surgery Saves Lives Checklist	Use of a checklist with 32 OR staff during simulation. The later computerized and implemented in OR for use during robotic-assisted gynecologic procedures over the course of 6 months	OR staff	Number of readmissions that occurred 30-days post surgery (measured pre/post-checklist intervention)	30 day readmissions pre-checklist (12) and post-checklist (5) were significantly reduced (p = 0.02)	OR staff members were not as motivated to use the checklist if a specific nurse was not present, potentially resulting in a pseudo-Hawthorne effect
Tsafrir [52]	Technology	Wireless audio headsets in a robotic operating room to improve the quality of communication	69 gynecologic and urologic cases conducted with headsets were observed and compared to 68 without	OR staff (n = 148)	A 14-point questionnaire was administered at the conclusion of each case to evaluate communication, performance, teamwork, and mental load (pre/post technology implementation)	Self-reported communication quality was better in cases where headsets were used (113.0 ± 1.6 vs. 101.4 ± 1.6; P < 0.001). Use of headsets reduced percentage of time with a noise level above 70 dB at the console (8.2% ± 0.6 vs. 5.3% ± 0.6, P < 0.001)	Ambient noise levels are not eliminated because the headset covers one ear
Van’t Hullenaar [54]	Training	Development of an ergonomic training program to provide instructions for ergonomic setup of the robotic console	Those in an intervention group received a short-written guide on correct ergonomic adjustment of the console and seat, an explanation on correct usage of the clutch controls, verbal coaching regarding posture and correct usage of the clutch	Surgical interns and residents	The Rapid Upper Limb Assessment (RULA) to evaluate ergonomic positioning via video recordings. Local Experienced Discomfort Scale and, NASA Task-Load Index (NASA-TLX) were evaluated (in control and intervention group)	Significantly lower economy of motion (EOM) was found in intervention group, P = 0.013. The overall RULA score for the left (P < 0.001) and right (P < 0.001) body halfs were significantly better in the intervention group. Participants did not report higher stress levels or muscle strain, as measured by the TED and NASA-TLX scores	Optimal interpretation and accuracy of the ergonomic setup are not guaranteed
Zattoni [57]a	Guidelines	Development of guidelines for conversion from robotic-assisted radical prostatectomy to open radical prostatectomy	20 simulations were performed over the course of seven months in a surgical theater for one surgical team to train on open conversions. For each simulation, the team was provided with a conversion protocol to follow for the conversion to open. Each simulation was timed (from the start of the conversion to skin incision) and video recorded. For each simulation, four main strategies were implemented to reduce errors: improving leadership, clearly defining roles, improving knowledge base, and surgical room reorganization. Guidelines were posted in the operating room after the training	Surgeons, Anesthesiologists, and Nurses	Time to conversion, number of errors, problems in the areas of environment, leadership,task sequence and allocation, planning, communication, training, and checklists were assessed prior to the implementation of the training and then reassessed after the training to identify improvement	The average conversion time was 130.9 (interquartile range [IQR] 90–201) seconds. Frequencies of the observed errors were as follows: lack of task sequence (70%), errors in robot movements (50%), loss of sterility (50%), space conflict (40%), communication errors (25%), lack of leadership (25%), and accidental fall of surgical devices (25%). By the last simulation, conversions were performed without errors and using 55.2% less time compared with initial simulations	The guidelines were developed for a specific type of surgery and may not account for other surgical complications and patient factors
Zattoni [58]a	Training	Evaluation of a standardized training and institutional checklist on improving teamwork during complications requiring open conversion from robotic-assisted partial nephrectomy	20 emergencies were simulated: group 1 performed simulations followed by a 4-h theoretical training; group 2 underwent 4-h training first and then performed simulations	OR staff	Conversion time number of errors, problems experienced during conversions in the areas of environment, leadership, task sequence and allocation, planning, communication, training, and checklists were assessed prior to the implementation of the training and after the training to identify improvement	Group 1 showed a higher time to conversion (TC) than group 2 (116.5 vs 86.5 s, P = 0.0.53). TC shows a progressive decline for both groups as the number of simulations increases (group 1, R2 = 0.7 and group 2,R2 = 0.61), but it remains higher for group 1. Lack of task sequence and accidental falls or loss of sterility were higher in group 1	The simulated environment produces shorter conversion times and may not accurately represent real-life experiences during robotic-assisted surgery

^aInterventions were analyzed using the same method