Overlapping Surgery: Do the Right Thing

Commentary on an article by Alan L. Zhang, MD, et al.: “Overlapping Surgery in the Ambulatory Orthopaedic Setting”

Healy, William L., MD*

doi: 10.2106/JBJS.16.00879
Commentary and Perspective

Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts Massachusetts General Hospital, Boston, Massachusetts

Back to Top | Article Outline


The practice of orthopaedic surgery in the United States is modulated by professional standards, ethical guidelines, federal and state regulations, and business models. In general, orthopaedic surgeons attempt to follow accepted standards and “do the right thing” for their patients. However, from time to time, changes and innovations are introduced to orthopaedic practice that can create conflict between generally accepted standards and guidelines.

During the last 2 decades, concurrent surgery has been implemented in many surgical practices. Concurrent surgery, which has also been called overlapping surgery or staggered surgery, refers to an attending surgeon booking two surgical cases in two separate operating rooms at the same time. Attending surgeons use teams of fellows, residents, physician assistants, and nurses to allow them to participate in parts of the operation and not be present for other parts of the operation. As the assistants perform parts of the operation in one operating room, the attending surgeon has the opportunity to perform another operation in another operating room. The term “critical portion” of the operation has been defined as the tasks that require the presence of the attending surgeon.

In their article, “Overlapping Surgery in the Ambulatory Orthopaedic Setting,” Zhang et al. evaluated 3,640 outpatient orthopaedic surgery cases, and they compared overlapping cases with non-overlapping cases. No differences were noted in the patient cohorts preoperatively. No differences were noted in the mean procedure time, total operating room time, and 30-day complications. The authors concluded that overlapping surgery in the ambulatory orthopaedic setting is a safe practice.

The practice of overlapping surgery has been debated in academic literature, professional publications, and lay media. Proponents of overlapping surgery have suggested that this practice can increase efficiency, can promote cost-effectiveness, can create the opportunity to care for more patients, and can increase reimbursements. In addition, overlapping surgery allows expanded opportunities for surgical education with graduated delegation of responsibility to assistant surgeons.

Opponents of overlapping surgery note that informed consent regarding when the attending surgeon will not be in the operating room is insufficient. In addition, the critical portion of operations may not be defined adequately. Positioning the patient, draping the surgical site, opening the wound, and closing the wound have been labeled as non-critical activities, but they can be associated with complications. Who determined that opening and closing a surgical wound are non-critical activities? Do patients agree with this definition? Wound complications can unnecessarily prolong care, and they may lead to adverse patient outcomes. Perhaps most importantly, overlapping surgery has been criticized because if something goes wrong during an operation, the attending surgeon may not be readily available.

All orthopaedic surgeons agree that we should always “do the right thing” for all patients at all times. However, orthopaedic surgeons do not always agree on what is the “right thing.” If a surgeon and a hospital wish to allow concurrent, overlapping, or staggered surgery in their organization, I suggest 5 important steps. (1) Obtain specific informed consent at least 2 weeks prior to the operation. This consent should include a specific description of what the attending surgeon will and will not do. (2) Define and implement throughout the organization consistent definitions for concurrent surgery (two operations being performed at the same time in two operating rooms with critical portions of the operation being performed concurrently), overlapping surgery (two operations being performed at the same time in two operating rooms with critical portions of the operation not being performed concurrently), and staggered surgery (two operations scheduled in two operating rooms back to back in which the attending surgeon completes one operation and moves to the second operating room for the second operation; the operations and the critical portions of the operations are not being performed concurrently). (3) Define the critical portion of each operation performed in the organization and explain this concept to patients who schedule these operations. (4) Record the specific presence and absence of the attending surgeon in the operating room record. (5) Monitor and evaluate patient outcomes associated with concurrent, overlapping, and staggered surgery.

When I undergo an orthopaedic operation, I want my surgeon to perform the entire operation. I accept the fact that assistant surgeons will work with my attending surgeon, but I want him or her to be at the operating table providing or coordinating my care. I think that most patients share this perspective. In my opinion, that is doing the right thing.

*Disclosure: The author indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, the author checked “yes” to indicate that he had a relevant financial relationship in the biomedical arena outside the submitted work.

Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated