|Surgical safety update|
|Tuesday, 28 August 2012|
The latest cases from the Confidential Reporting System for Surgery
An appendix too far
An 18-year-old male with right iliac fossa pain was diagnosed with acute appendicitis and underwent lengthy laparoscopic appendicectomy, undertaken by a trainee with his consultant supervising but unscrubbed. Post-operatively the patient failed to improve clinically and developed fluctuating pyrexia. Ultrasound suggested the presence of a pelvic abscess and the patient returned to theatre for laparoscopic drainage. At laparoscopy, a mass was found in the right iliac fossa which proved difficult to dissect. The procedure was converted to midline laparotomy. At re-operation an indurated mass with an inflamed appendix was found at the ileocaecal junction. On this occasion appendicectomy was undertaken successfully.
Subsequent pathological examination of the previously resected “appendix” revealed a piece of mesenteric fat which had been mistaken for the appendix by the trainee and his mentor.
In a difficult laparoscopic appendicectomy, early conversion should be considered by the surgeon, inexperienced or otherwise. The unscrubbed supervisor has responsibility for the procedure and should either have scrubbed for the procedure or supervised the trainee more closely. The Advisory Board suggested that an escalating series of steps should occur in difficult situations. Step 1: supervisor scrubs-in (increases their situational, tactile and perceptual awareness);
Mistaken anatomy 1
A 69-year-old male underwent resection of an advanced squamous cell carcinoma of the right mandibular alveolus. Temporary tracheostomy, selective neck dissection, segmental mandibulectomy, dental extractions, reconstruction with fibula free flap and insertion of an open gastrostomy tube were planned.
Timings for the procedure proved difficult. The first date for surgery was declined by the patient. There were no beds available on the day prior to the second planned date for surgery, so the patient was advised to attend on the morning of the procedure. An ITU bed had to be secured. Start time was delayed. The procedure was complicated and took until 19.00. Due to lack of availability of gastrointestinal surgeons, planned gastrostomy was deferred and an NG tube placed in-situ. Post-operative x-rays demonstrated that the NG tube was incorrectly positioned and three further (futile) attempts were made to re-site this.
The following morning, the patient was placed on the emergency list for gastrostomy which was postponed, due to other cases, until the early evening when he was taken back to theatre and a gastrostomy tube inserted by the on-call surgical registrar, in a lengthy procedure. Early feeding via gastrostomy was commenced, but the patient failed to improve, developing pyrexia and increasing CRP over the next three days. When he developed diarrhoea and epigastric pain on the fourth post-operative day, an abdominal CT scan was undertaken, with contrast introduced down the gastrostomy. This revealed the ‘gastrostomy’ to be sited in the mid-transverse colon with some extravasation of contrast. At re-look laparotomy the feeding tube was removed from the colon, a transverse loop colostomy was undertaken and the gastrostomy re-sited appropriately.
Subsequently, the patient had a prolonged hospital stay while he learned to manage his stoma, which was successfully reversed three months later.
CommentsComplex cases require meticulous pre-operative planning. This case resulted in an adverse outcome because of a series of complications. Day-of-surgery admissions are feasible and save hospital resources, provided protocols are adhered to. In a case such as this, some surgeons might have considered pre-emptive use of a percutaneous gastrostomy (PEG). If the trainee experienced problems during the latter procedure help should have been sought at an early stage.
Mistaken anatomy 2
A 73-year-old man presented with a one-year history of a change in bowel habit. He underwent colonoscopy where a very large polyp, which could not be negotiated, was found in the recto-sigmoid colon. Biopsies confirmed a tubulovillous adenoma (TVA) with high grade dysplasia. CT scan demonstrated a 6cm mass in the recto-sigmoid, with no sign of invasion or metastatic disease.
The patient was counselled and scheduled for resection. Before operation could be undertaken however, the patient became unwell with signs and symptoms of large bowel obstruction due to polyp intussusception.
The patient was admitted from clinic and resuscitated. The next day it was decided that he should undergo defunctioning colostomy as an emergency, to prevent perforation. The patient was marked for a transverse loop colostomy.
As it was a weekend, I discussed this with the GI consultant on-call and arranged that this would be done on the emergency list under his care. The operation was carried out by an experienced trainee with an interest in colorectal surgery. The consultant was not present in the operating theatre but was on-site and available if needed.
The operation appeared to proceed without problem. However, at 72 hours post-operatively, the patient developed a cardiac arrhythmia and was transferred to the CCU. This was thought to be due to magnesium depletion (not uncommon following obstruction and a large TVA). He required magnesium infusion and at one stage, cardioversion. Shortly afterwards, the stoma developed a high output (2-3 litres/24hr) and skin excoriation. I realised that something was wrong and arranged for contrast to be instilled down each limb of the stoma via Foley catheters. The x-ray suggested that one catheter was in the stomach and the other in the duodenum. This was confirmed by CT which demonstrated that the distal stomach had been brought out and fashioned into a loop stoma.
I discussed the safest way forward with my colleagues. We undertook urgent laparotomy as a two-consultant procedure, closing the gastric stoma around a Foley catheter, placed a feeding jejunostomy and undertook a Hartmann’s procedure, as when the intussuscepted sigmoid polyp was reduced, intra-intussusception perforation occurred. I had a difficult conversation with the patient and family, explaining what had happened and made an unreserved apology. The patient made a slow recovery and was eventually discharged home. Final histology showed no evidence of invasion. A hospital serious untoward incident inquiry was held.
This case reinforces the message that a call for help (or even just a quick check; “Is this ok?” “Does this look right?”) is not an admission of failure, but good professional practice. During surgery the anatomy was misidentified by the trainee who failed to identify greater and lesser omentum and taeniae coli and didn’t request assistance. If a patient does not progress as one might expect after an operation, question what happened during the procedure. Good communication with immediate explanation and apology for the error helped to resolve potential conflict. Where corrective surgery has to be undertaken to resolve a problem, a two-consultant procedure is good clinical practice. l
Frank CT Smith
CORESS Programme Director