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Illustration of two surgeons operating within a box being opened
Illustration by Bruno Mangyoku

A Cut Above

A “black box” for the operating room is leading to improved training for physicians and better knowledge of surgical errors


Professional athletes use video analysis and other technologies to study their technique, correct errors and improve performance. Why not surgeons too?

Dr. Teodor Grantcharov, a professor of surgery at U of T and a staff surgeon at St. Michael’s Hospital in Toronto, has developed a surgical data recorder that documents all the details of an operation: it records video of the procedure and the operating room and audio of the team’s conversations; it gathers software data from all medical devices, such as those that monitor the patient’s vital signs; and it even logs the temperature and decibel level of the operating room. By borrowing a concept that has helped make aviation such a safe industry, Grantcharov, who holds a Canada Research Chair in Simulation and Surgical Safety, hopes his surgical “black box” will lead to similar safety improvements in surgery.

The idea struck Grantcharov in the late 1990s, when he was a surgical resident in Copenhagen. He had often been told he was an excellent surgeon, and he believed it, until the day he watched some video taken of his minimally invasive laparoscopic procedures. “It was embarrassing how slowly I worked, how inefficient my moves were,” he recalls. These were small details that didn’t harm the patient, but he says, “I realized I could have done much better.”

Grantcharov, who went on to earn a PhD in objective assessment of surgical performance, consulted Air Canada’s corporate safety board to understand the role black boxes can play in identifying and fixing safety risks. Grantcharov’s “black” box – originally blue but now a neutral white – is the size of a thick laptop and sits outside the operating room, wirelessly connected to systems inside the room. He and his research team are currently developing optical technology the surgeon will wear like a pair of glasses, recording exactly what the surgeon sees.

Grantcharov is the senior author of a study about the surgical black box published last May. In 54 bariatric surgeries done through minimal incision, video showed that in 38 there were 66 “preventable events,” including everything from tangled sutures and minor bleeding to membrane tears. Three-quarters of these went unnoticed by the entire operating team. In another study, Grantcharov found that surgical residents who received black-box feedback improved more than residents who did not. Grantcharov, who has been using the device for more than a year, considers it a source of continuous education to improve his technique. Patients, he says, express confidence in the increased transparency.

By spring, Grantcharov expects the black box to be installed in four other hospitals, in Holland, Denmark, the U.S. and Chile, all reporting back to St. Mike’s. Surgeons worldwide are enthusiastic, but Grantcharov has received occasional resistance from those who don’t want their methods questioned. “The operating room is probably one of the most secretive places in modern society,” says Grantcharov, “but our safety record is not as good as it should be.” Depending on the type of procedure and other variables, up to 17 per cent of operations result in major complications, half of them preventable, he says, and more than 8,000 Canadians die every year as a result of medical errors.

Some surgeons worry that the black box could increase malpractice issues, and Grantcharov acknowledges that if required by law, the video must be submitted. But he says the whole purpose is to reduce or prevent those adverse events in the first place. “I’m confident we can prove we can reduce the number of errors, prevent complications and use operating rooms more efficiently.” Once commercialized, he expects the black box to become the standard of care for all types of surgeries worldwide.

Dr. Teodor Grantcharov explains how his surgical “black box” improves performance and safety

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  1. One Response to “ A Cut Above ”

  2. Judith Katz (Vig) says:

    Congratulations to Dr. Grantcharov and his team. Dr. Grantcharov is spot on in declaring “The operating room is probably one of the most secretive places in modern society." His ‘white’ box will be a tremendous asset to surgeons and patients.