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.

1. Dr. Prahlada N.B
MBBS, MS(PGI), MBA, MHA
Karnataka ENT Hospital & Research Center,
Chitradurga

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. Advantages of Time Management

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. Advantages: Patient
 Economical
 Less discomfort
 Less chance of operating wound infection
 Less anaesthesia risk
 Less OT risk
 Less hospital stay

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. My average timing!
 CM + Tympanoplasty - 26 minutes
 MRM + Tympanoplasty - 52 minutes

8. Why?
 Al Shifa Hospital, Perinthalmanna

9. Why?
 Surgical Camps

10. Why?
 MBA
 Father of Scientific Management
 Frederick Taylor (1856-1915)
 Taylorism

11. Taylorism
 Analyzed and synthesized workflows
 Improving economic efficiency &
 Enhancing labor productivity
 Standardization of process steps
 Time and motion studies

12. Surgical Time audit
 Recording all events in OT
 Classification of events
 Analysis of events

13. Surgical time audit
 Recording of all events in OT
 Pre-operative
 Intra operative
 Post-operative

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. 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. Surgical time audit
 Classification of events
 Very important
 Not particularly important
 Worthless

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. 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. Factors affecting Surgical time

20. Patient factors
 General physical condition
 Risk factors
 Type of pathology
 Intra-op bleeding

21. Surgeon factors
 Attitude
 Training
 Philosophy
 Planning
 Execution
 Delegation
 Team work

22. Practice makes man perfect!

23. SWOT Analysis

25. TQM – Six Sigma

26. Anaesthetist
 Attitude
 Training
 Philosophy
 Team work

27. Type anaesthetist
 Superficial
 Gas Man!
 Freelancer

28. Staff factors
 Attitude
 Training
 Team work

29. Staff Motivation
 Discipline
 Participation and involvement
 Time management
 Morale
 Skill development
 Communication

30. Learn the Kaizen way!

31. Operation theatre
 Design
 Lighting
 Air conditioning

32. Operation theatre

33. Equipment
 Right equipment
 Working equipment
 Serviced!
 Multi-use

34. Microscope

35. Equipment
 Micro-instruments – double ended
 High speed micro drill
 Good burrs
 Patent suction tips!
 Scissors which cut!

36. 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

37. Surgical Approach
 Transcanal
 Endomeatal
 End-aural
 Post-aural

38. Surgical Approach
 Trans-canal approach
 Post-traumatic perforation - < 3 months

39. Surgical Approach
 Endomeatal approach – Wide canal
 Post-traumatic perforation - > 3 months
 Central perforation – other aetiology
 < 3 months.

40. Surgical Approach
 End-aural approach – Narrow Canal
 Posterior Central perforation
 When Cortical mastoidectomy is not planned

41. 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

42. 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