Operating the night before daytime surgery appears to have no effect on safety

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1. There is no difference in conversion from laparoscopic to open cholecystectomies among surgeons who had vs. had not operated the night prior to elective daytime laparoscopic cholecystectomies. 

2. Operating the night before does not increase risk of iatrogenic injury or death compared to not operating the night before an elective laparoscopic cholecystectomy. 

Evidence Rating Level: 1 (Excellent) 

Study Rundown: Sleep deprivation may impair surgical performance, but insufficient evidence exists to support this claim. In this study, the number of complications by surgeons who operated the night before daytime laparoscopic cholecystectomies were compared to the number of complications by the same surgeons at a time when they had not operated the night prior to performing daytime laparoscopic cholecystectomies. The primary outcome was conversion from laparoscopic to open cholecystectomies. Secondary outcomes included iatrogenic injuries or death. There was no difference between conversion rates of surgeons who had (2.2%) vs. had not (1.9%) operated the night prior to elective daytime laparoscopic cholecystectomies (OR 1.18; 95% CI, 0.85-1.64).  No difference was found between iatrogenic injuries (0.7% vs. 0.9%, OR, 0.77; 95% CI, 0.43-1.37) or death (0.2% vs. 0.1%). Strengths of the study include its large sample size, as well as balanced characteristics between the two comparison groups including matching the same surgeon in the control group to account for variability in surgical expertise. Limitations include unknown variability in the level of fatigue or length of time surgeons spent operating the night prior to daytime surgeries. The study affects clinical practice by providing the first population-based evidence that suggests sleep deprivation does not impair surgical performance, which may influence regulation of policies affecting surgeon work hours.

Click to read the study, published today in JAMA

Click to read an accompanying editorial in JAMA

Relevant Reading: Risks of complications by attending physicians after performing nighttime procedures

In-Depth [retrospective cohort study]: This study included 331 individual community surgeons from 102 hospitals. Daytime elective laparoscopic cholecystectomies were performed between the hours of 7AM to 6 PM. “At risk” surgeries were defined as daytime surgeries performed by surgeons who had done a non-elective operation between the hours of midnight and 7 AM the previous night. 2078 “at risk” elective cholecystectomies were identified and were randomly matched to 8312 comparison surgeries performed by the same surgeon in the same year on days when the surgeon had not operated the night before for a total sample size of 10390 procedures. Of the “at risk” surgeries, 2.2% (95% CI, 1.6%-2.9%) were converted to open cholecystectomies vs.1.9% (95% CI, 1.6%-2.2%) of comparison surgeries. Iatrogenic injuries occurred in 0.7% (95% CI, 0.3%-1.0%) vs. 0.9% (95% CI, 0.7%-1.1%) of “at risk” vs. comparison surgeries respectively. Less than 0.2% of patients in “at risk” surgeries died vs. 0.1% (95% CI, 0.0%-0.2%) of patients in comparison surgeries. None of the findings for conversions, iatrogenic injuries, or deaths were statistically significant.

By Gayatri Boddupalli and Brittany Hasty 

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