Evaluation of the Effectiveness of Immediate Preoperative Team Discussion in Enhancing Surgical Safety and Clinical Outcomes in Head and Neck Free Flap Reconstruction

Head and neck free flap microsurgical reconstruction remains among the most complex and resource-intensive procedures in reconstructive surgery (Chow 2020; Papanikolaou et al. 2023). Success depends not only on technical expertise but also on seamless coordination among surgical, anesthetic, and nursing teams (Gao et al. 2017; Eskander et al. 2018). Traditionally, preoperative planning has relied on multidisciplinary discussions conducted days before surgery (Kern 2003; Sato et al. 2025). While effective for strategic preparation, these meetings often fail to address evolving patient conditions, last-minute logistical issues, or intraoperative contingencies. This time gap may foster miscommunication and uncertainty, increasing the burden of intraoperative decision-making (Undre et al. 2006; Sato et al. 2025). To bridge the gap between early preoperative planning and real-time operative readiness, the concept of the Immediate Preoperative Team Discussion (IPTD) has emerged. IPTD is a structured, real-time, small-group discussion conducted immediately prior to surgery. The workflow of IPTD was considered in the decision-making process for performing the surgical procedure. The surgical team reviews patient information, including medical history, pathology, comorbidities, medications, recent clinical changes, and preoperative evaluations such as laboratory results, imaging, and consultations. The team then confirmed the surgical plan, including operative goals, alternatives, and task allocation, supported by relevant literature and discussion of case-specific considerations. Based on this discussion, the main surgeon assigns surgical tasks according to each trainee's experiences and skills (Figure 1). This near-real-time synchronization ensures operative plans remain current and aligned across disciplines. The clinical impact of IPTD was evaluated through a retrospectively review of113 patients who underwent advanced head and neck cancer surgery with free flap reconstruction between March 2023 and March 2025. Patients were divided into an IPTD group (n = 21) and a control group without IPTD (n = 92). Clinical outcomes were compared, including operation time, ICU and hospital stay, and complications. Additionally, 479 medical professionals completed a survey assessing IPTD's perceived impact on surgical safety, efficiency, and education. The study cohort comprised 21 IPTD and 92 control patients. While age (p = 0.255), sex (p = 0.934), and flap type (p = 0.457) were comparable, TNM staging differed significantly (p = 0.016); the IPTD group had a higher proportion of advanced disease (76.19% Stage IVA, 19.05% IVB). Despite this complexity, the IPTD group demonstrated superior clinical efficiency. Total operation time (673.52 ± 107.57 vs. 792.01 ± 119.51 min, p < 0.001) and reconstructive time (399.29 ± 83.36 vs. 531.89 ± 104.29 min, p < 0.001) were significantly shorter. Flap survival was 100% in the IPTD group versus 98.91% in controls (p = 0.635). Notably, the IPTD group required no unexpected second operations, whereas the control group necessitated debridement in 7.61% and flap revision in 1.09% of cases (Table 1). Postoperative recovery was also faster, with reduced ICU stays (5.48 ± 1.50 vs. 7.01 ± 2.53 days, p < 0.05) and total hospital stays (16.33 ± 1.83 vs. 20.10 ± 6.14 days, p < 0.05) (Figure 2). Regarding safety, the complication rates demonstrated only a trend toward reduction, without a significant difference between the two groups (9.52% in the IPTD group vs. 14.13% in the control group) (Figure 2). However, we further analyzed the interaction between complication status and ICU stay. In the control group, the presence of postoperative complications was associated with an increased ICU stay. In contrast, in the IPTD group, ICU duration remained relatively stable even in the presence of complications (Figure 3). This finding indicates that the IPTD workflow may buffer the impact of adverse events, preventing them from translating into prolonged intensive care requirements. Equally important is the perspective of the surgical team. A survey of 458 clinicians—including postgraduate year trainees (33.62%, n = 154), residents (37.55%, n = 172), and attending surgeons (28.82%, n = 132). In terms of IPTD exposure: 57.76% (n = 279) had participated in at least one IPTD session. 42.24% (n = 204) had no prior exposure. Among those with IPTD experience: 61.65% (n = 172) had attended once; 21.86% (n = 61) had attended 2–5 times; 8.24% (n = 23) had attended 6–10 times; 8.24% (n = 23) had attended more than 10 sessions. Perceptions of IPTD were assessed using a 5-point Likert scale. The results revealed generally positive attitudes: Reduction in surgical complications: 4.17 ± 0.90, reduction in unplanned reoperations: 4.17 ± 0.90, improved team cohesion: 4.17 ± 0.89, enhanced surgical proficiency: 4.16 ± 0.87, increased surgical success rates: 4.15 ± 0.90, and perceived irreplaceable value of IPTD: 4.00 ± 1.03 (Figure 4). These findings suggest broad agreement among surgical team members regarding the practical value of IPTD in improving perioperative outcomes and team collaboration. IPTD is a structured, small-group meeting held immediately before surgery that serves as a final checkpoint to reassess patient status, refine surgical plans, and anticipate intraoperative risks (Sato et al. 2025). It allows the team to address last-minute changes—tumor margin updates, vessel availability, anesthesia adjustments, or the need for vein grafting—while fostering a shared mental model of the operation. Unlike routine preoperative briefings, check list, or surgical timeouts (Haynes et al. 2009; Fourcade et al. 2012), IPTD promotes dynamic, real-time, case-specific dialogue among the team members, thereby reducing cognitive load during surgery and allowing the team to operate with greater clarity (Undre et al. 2006; Treadwell et al. 2014; Zhou et al. 2021; Griffiths et al. 2023; Lingard et al. 2005). Our results provide empirical support for these theoretical benefits. Despite the IPTD group presenting with significantly more advanced disease (higher prevalence of TNM Stage IVA/IVB, p = 0.016), the total operation time was reduced by approximately 2 h (673.52 vs. 792.01 min, p < 0.001). This paradoxical finding—greater surgical efficiency despite higher case complexity—suggests that the preoperative synchronization facilitated by IPTD streamlines the intraoperative workflow. This indicates that IPTD could provide the surgical teammates a broader improvement in workflow or perioperative management. Furthermore, this efficiency translated into resource conservation, evidenced by significantly shorter ICU stays (5.48 vs. 7.01 days) and total hospital stays (p < 0.05). Although our data showed IPTD group could decrease the reconstructive operation time, ICU and hospital stay as to the control group without IPTD, the complication rates showed only a trend toward reduction but no statistical difference between both groups (9.52% in IPTD vs. 14.13% in controls). Further studies with larger sample sizes are required to better elucidate the relationship between IPTD and the complication rate. Educationally, IPTD offers unique value. Trainees benefit from observing senior surgeons verbalize their operative logic, engage in collaborative reasoning, and consider intraoperative scenarios in real time (Chang et al. 2023). This exposure to high-level decision-making is rarely accessible in passive observation. Models like the “Whiteboard Timeout” and “Teaching Time-Out” have emphasized similar benefits (Guidolin et al. 2020; Griffiths et al. 2023), but IPTD adds structure, frequency, and strategic depth. Incorporating IPTD into surgical education could enhance not only technical knowledge but also leadership and systems thinking. Some limitations of this study should be acknowledged. This was a retrospective, single-center analysis with a relatively small IPTD cohort. Potential confounding factors, including variations in surgeon experience, were not fully controlled. Although reductions in operative time and hospital stay suggest potential cost-effectiveness, formal economic analyses were performed. Larger prospective, multicenter studies are warranted to confirm these findings and assess generalizability. In conclusion, IPTD was associated with improved operative efficiency, reduced hospital lengths of stay, and higher reported team satisfaction, while maintaining comparable safety profiles. As surgical complexity increases and resources become more constrained, structured frameworks like IPTD may serve as valuable tools. Based on these observed correlations, we suggest that formalizing IPTD, incorporating it into safety protocols, and utilizing digital coordination tools could facilitate broader applicability across specialties. In the context of head and neck microsurgery, IPTD represents a potential model for delivering safer, more efficient, and team-integrated care. The authors have nothing to report. Dr. Yur-Ren Kuo serves on the Editorial Board of Microsurgery. The study was conducted according to the guidelines of the Declaration of Helsinki and was approved by the Institutional Review Board of Kaohsiung Medical University Hospital [KMUHIRB-E(I)-20230133] and [KMUHIRB-E(I)-20240149]. Informed consent was obtained from all subjects involved in the study. The authors declare no conflicts of interest. The data presented in this study are available on request from the corresponding author. The data are not publicly available due to privacy and ethical concerns.