R. Brühl-Day, Med Vet, Dipl SA Surgery
Facultad de Ciencias Veterinarias-Universidad de Buenos Aires
Buenos Aires, Argentina
Surgical mistakes can start as soon as the primary steps into the making of a diagnosis are taken. All patients must have a history as accurate as possible. This information can be very helpful to understand some underlying diseases. (i.e., a very thin patient shows up that there is no fecal analysis done ever) and from time to time directed towards a non surgical treatment. But a good clinical writing does not always replace a correct medical action. A suitably clinical record with no sustain of a good diagnosis, treatment and patient follow up is merely an artifact. The main objective is a correct medical attention and the complementary is represented by the clinical record which is merely a reflection of the professional work. Occasionally the best surgical procedure is the one not carried out, but as surgeons, we know we can be confronted with a mistake either made by us or made by somebody else that we have to solve. In the preoperative phase, a surgeon can have a deficient or insufficient valuable laboratory profile which can lead to erroneous conclusions or be incompetent to properly interpret lab data. What about diagnostic imaging? When and where take a radiograph? A traumatized patient does not need an immediate X-ray as soon as presented for a consultation. Initially we have to assess what condition is the patient showing before asking for a "picture." "Reading" the radiograph can lead to misguided interpretations if we are not trained to do so. Insufficient number of radiographs or positions may hide some other accompanying disease, other than the one seen at a glance. Even with a good report, it must be remembered that we do not treat a picture, we deal with patients. It is known also that what an X rays shows on occasions follow behind the clinical manifestation of a disease and / or its medical signs (i.e., pneumonia). Patient stabilization must always pave the way to a surgical procedure whenever possible. A surgeon must know its limitations by the skills he or she knows to have. It is important as well to develop auto criticism in order to evaluate the execution or the way a procedure was done and self motivate to correct mistakes that may have passed unnoticed to others. Every surgical procedure must be assessed, evaluated and planned ahead when dealing with elective surgeries. Planning may save time in front of a problem in the middle of a simple or intricate surgical procedure. The loss of "precious seconds" may lead to further complications. When determining the surgical risk, the benefits of a certain surgical procedure must be weighed against the potential of creating damage. Surgery must be understood as taking action to make available a solution for a medical problem, being it the complete removal of a mass, relieving an obstruction or simply offer a better quality of life. Doing a surgical procedure and leave a patient in an equal or worst condition has no justification. The anesthetic risk must also be evaluated as well as considering age and general condition of the patient and if the actual physical status may have some influence on the postoperative recovery. Occasionally lengthening the procedure has to be carried out and not knowing that the risk of infection duplicates every hour the incision is opened, or ignoring the classification of surgical wounds related to the degree of contamination, can seriously impair an otherwise successful surgery. The rate of infection with no antibiotics in procedures that last less than one and a half hours is 1.6%. for those longer than one and a half hours is 8%. With the use of antibiotics in procedures that last less than one and a half hours is 0.8%. for those longer than one and a half hours is 3.3%.
When confronted with a surgical emergency scheduling according to experience must also be present because there is where you are going to jump from plan A to B, refer the case or have a second opinion. A frequent mistake is not to know well the patient, which may guide to an inaccurate evaluation of the case (i.e., ovariectomy in a male feline). Some veterinarians do not know how to refer or when to refer a case. Sometimes is because of a false sense of guilt: "somebody else is going to know if I made a mistake or have not known how to deal with such a case"; what an embarrassment!!! And what about the patient??? This is our primary goal and the patient should be above any false feelings. Such a scenario may conduct to an unwillingness to refer. Sometimes the practicing veterinarian does not know how to refer, because of distance, economical problems or any other reason the social and economical reality of each and every country dictates. Some surgeons do not look after the best solution for the patient's problem and try to solve it the "best way they can." When complications originate due to some of the above-mentioned aspects of a mistake, at times there is a lack of knowledge on how to solve them adequately, which may lead to more trouble.
What about the use of inadequate instruments? Surgeons know it is not the same to use atraumatic needles vs. double looped regular needle. Microscopic tissue trauma can add more tissue damage. Use of a wrong instrument, especially in a delicate procedure can aim towards a faulty technique or lack of the adequate gentleness with the tissues.
In certain countries where the economic situation may inflict a coup in the general development of the daily work, mistakes can emerge due to economical limitations. Something perhaps difficult to understand for the practitioners from developed countries, but a real scenario for others trying to do their best sometimes under such a reality.
Audacity can appear on top of the deficient preparedness to work with or in a team. Audacity can also lead to a wrong understanding and not consulting with experienced colleagues. This way they may not anticipate problems that will take place later on. Among other reasons for generating a surgical mistake we can include lack of adequate knowledge of surgical and regional anatomy that will lead to an inappropriate or faulty technique. (i.e., rupture of the pelvic diaphragm). Scarcity of correct erudition of a surgical technique is another route directed towards a surgical error. There is a straight connection between formation, training and actualization. Newer and safer techniques are offered sometimes on a daily basis. Not updating is a bad mistake that can be associated to some surgical procedures.
Insufficient fasting can put on the right track to aspiration pneumonia and early termination of a programmed surgery. Different situation will be under emergency circumstances when this condition will be handled appropriately following the established procedures in order to avoid additional mistakes. Incomplete surgical area preparation (i.e., trimming) may create complications during the surgical procedure if additional room is needed or add extra contamination in the middle of a surgery. Defective sterilization, as well as deficiency in controls or prolonged storage of the surgical apparel or instruments can steer to a potential error. All equipment must be checked before surgery to become familiarized with some special tools needed for a better or safer procedure. Not knowing how to use it properly, and lack of maintenance are other factors sometimes combined in the road to failure.
It has been defined that all suture material is a foreign body Therefore the material to be used must be carefully chosen. The size should be the minimal to give the needed strength to hold the tissues in place to keep the foreign body reaction to a minimum. Here comes to our attention defective tying technique, tying knots too tight because not knowing how much tension should be applied or not having self-confidence. Rough handling of tissues are sometimes associated with lack of adequate instrumentation. When getting a biopsy there can be an erroneous sample taking or sample obtained from the wrong side. Inadequate anesthesia (i.e., during laringoscopy) may lead to an erroneous interpretation of laryngeal cartilage movement or soft palate position.
An insufficient safety margin left over after resecting a neoplasia may give chance for a recurrence when removing a tumor. Not to mention to overlook catheters, gauze sponges within a cavity or a knotted catheter inside the bladder after the abdomen is closed or realizing about them when a control X-ray is taken postoperatively. To forget a purse string suture after repairing a ruptured pelvic diaphragm can be a complication for the patient when trying to function normally. A minor error for not observing can direct to a major problem. Dealing with dead spaces originates another chapter about when, where and what type of drains should be used to prevent a postop problem like seromas, dehiscence and eventually evisceration. When leaving clots, traumatized, devitalized or necrotic tissues, the level of contamination needed for infection will be dramatically reduced. It has been mentioned that up to 105 microorganisms per gram of tissue is considered contamination and 106 is infection. As an example, when clay is left behind in a traumatic wound after being cleaned and debrided the level to reach infection is only 102 microorganisms per gram of tissue.
In the O.R.
The surgeon is responsible for the general and conceptual aspects that occur around him, for instance if collaborators are in their respective place and doing the job indicated for; like control of hypothermia, checking heating elements for the patient. Reports of burns due to heating pads or faulty dispersive electrodes when using an electroscalpel are abundant in the surgical literature
Accurate patient positioning can save extra time and further difficulties in some surgical procedures. Having all may possibly be necessary during any surgical procedure saves also operative time.
Wound monitoring for edema, inflammation that persists, increase of local temperature, attempts to bite, licking excessively or chewing the area by the patient are warnings that must not be overseen. Any increase in these signs during the 4 or 5 days postop may lead to dehiscence and/or infection. Keep in mind that lack of pain medication may show a similar path to self mutilation or early drain, or bandage, or stitches removal. An overly tight bandage can also direct to self mutilation because of ischemia and / or pain. Wound cleaning will allow for a rapid assessment on how is it healing or an early detection of a potential complication. It has to be known that certain procedures will produce some kind of secretion and how it should be cleaned in order to prevent an owners complaint (i.e., when using an ESFD around the pins entrance can be found some secretion that may look like pus. Owner explanation on how to do a gentle daily cleaning will avoid further complications). A rational use of antibiotics will prevent the development of resistant strains of bugs. Culture and sensitivity should be something standard. Antibiotic abuse is supposed not to be employed to hide surgical mistakes
When considering an infection a thorough evaluation of the wound and patient has to be made initially. Extension of the infection plus the experience on how to manage it and possible treatment will give an opportunity to success.
Nutrition has been the star of the late 90´s. As it was said many times "if the gut works, use it." Enteral nutrition must be restarted as soon as possible to prevent collateral damages in some cases (i.e., atrophy of intestinal villi).Removal of catheters, drains, stitches has to be well planned in order to avoid other postop complications (i.e., stenosis of a stoma, phlebitis, recurrence of a fluid collection).
We must not forget the "law suit industry" that varies among different countries. In most it is the owners duty to demonstrate the veterinarian malpractice and not the doctor its innocence. Anyhow this is no excuse for not trying to do our best in order to avoid or prevent a surgical mistake. It is not mandatory for the professional to come across a diagnosis but to make everything possible on his side to reach it, contributing for with his knowledge, his medical thinking as well as with the occasional aid of consulting with colleagues possessing larger experience. Carelessness or negligence must not be sheltered with the mistake justification.
Mistake: error, inaccuracy, oversight, blunder.
Malpractice: unskillful and faulty medical or surgical treatment.
Iatrogenic: said of any adverse condition in a patient resulting from treatment by a physician or surgeon.
Inexperience: lack of experience or knowledge.
Rodolfo Brühl-Day, Méd Vet, Dipl SA Surgery