Background: Teamwork is increasingly being recognized as an important factor in surgical outcomes,
especially in rare procedures requiring advanced technical skills, such as the middle
fossa craniotomy (MFC) approach to vestibular schwannoma resection. The MFC requires
excellent communication, swift, yet collaborative, decision-making, and an understanding
of the leadership structure in the operating room. Decision-making collaboration extends
outside of the operating room (OR) to the choice of the particular type of patient
characteristics which would most likely benefit from specific approaches. Examination
of outcomes from a recently formed team provides an excellent context to explore team
formation on patient outcome.
Hypothesis: In acoustic neuroma surgery, development of a specialized operative team that undergoes
team-building exercises, collaborates in the choice of surgical approach, shares OR
instrumentation, and conducts a relatively high rate of rare procedures will result
in reduced operative times and improved patient outcomes.
Methods: A retrospective review of patient outcomes (operative time, total length of stay,
discharge placement, complications, facial nerve and hearing outcomes, among other
variables) in middle cranial fossa excisions was conducted. Qualitative measures,
such as communication styles and collaborative decision-making, were reviewed.
Results: A multidisciplinary surgical team was recently formed, led by a neuro-otologist and
neurosurgeon. Previously, both surgeons had performed the surgeries independently
and were highly experienced in all craniotomy approaches in the cerebellar pontine
angle. A total of 35 middle fossa procedures were performed between Sept 2013 and
Aug 2016, at a rate of ~11 procedures each year. Average patient age and tumor size
remained nearly constant over the 3 years, reflecting a consistency in the method
of patient selection. Average operating time was significantly reduced from the first
year to the second and third years (p=.006). Average OR time was 3.0 hours, reducing
to 2.5 hours in the second and third years. Average length of hospital stay decreased
from 3.0 days to 2.5 days (n.s.) and discharge was usually to home.
Of the 34 cases with full hearing data, hearing preservation was achieved in 28 cases
(82%, significantly different from chance, p < .001). Post-operative word recognition scores increased with increasing team experience
(Average = 58%, 73%, and 79% for years 1, 2, and 3). Similarly, in procedures that
did not result in complete deafness, the difference between pre- and post-operative
word recognition scores decreased with increased team experience (average reduction
in score: 35%, 25%, and 18%). A House-Brackmann facial nerve grade of greater than
1 or 2 was too rare (1 instance each year) to detect differences with team expertise.
Discussion: The results suggest that formation of an effective team plays an important role in
improving microsurgical outcomes, reducing time in the OR and trending toward better
hearing outcomes. Improvements in communication during the first year, along with
clear priorities as defined by the leadership team resulted in a cohesiveness which
improved patient outcomes. The challenges of the MFC approach can effectively be managed
through the development of a multidisciplinary team, ultimately benefitting the patient.
