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  Do call for help

  
  
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  Don’t burn any bridges

  
  
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  Do remain calm and be decisive

Things go wrong in the operating room; that’s no secret. If reports are correct, there are more than 4,000 surgical “never events” per year in the United States.¹ Fortunately for our patients, most experienced surgeons anticipate such obstacles and both patients and surgeon usually survive unscathed. When things go wrong in the OR, it is imperative that we are adequately prepared to handle unexpected challenges and still provide exceptional surgical care.

The Institute of Medicine’s report, “To Err is Human,” sparked a national outcry for safer medicine. Surgical checklists and ACGME-mandated reduced-hour work regulations have been instituted to reduce the effects of human error on patient outcome; the results of the latter have been mixed.² We borrow heavily from aviation standards whose protocols attempt to diminish the impact of human mistakes; nevertheless, a hospital is complex machinery whose parts are imperfect humans. Weekly quality improvement (QI) conferences held across U.S. academic surgery departments highlight the fact that complications still occur with some regularity. Some of these morbidities are related to patient disease while others can be attributed to error in judgment and technique. Perhaps the most important variable separating potentially catastrophic outcomes versus tolerable morbidity is whether surgeons employ sound and calm judgment in the face of adversity.

Throughout surgical training, and as evidenced by inclusion in new residency training milestones, intraoperative surgical decision making is stressed as a hallmark of a facile and safe surgeon. Despite general consensus that judgment in the OR is important, the literature evaluating this relatively amorphous and subjective concept is scant. A very eloquently written article on the subject of naturalistic decision making and situational assessment necessitates direct quoting:³

It renders credence to the concept that we do not often have the luxury of a perfect solution intraoperatively; rather, the goal is to achieve a safe outcome in the face of rapid decompensation or unexpected obstacles.

The combination of a high-stress and high-stakes operation can lead to extremely emotional responses to intraoperative difficulties, both from the surgeon and the nurses. A 2008 New York Times article “Arrogant, Abusive and Disruptive—and a Doctor” illustrates the much feared scenario where a patient suffered because the surgeon did not listen to the nurse. To be sure, it happens. Pronovost, a patient safety guru, noted that arrogance and the culture of fear leads to poor patient outcomes.⁴ For the vast majority of surgeons who don’t throw instruments or scream at nurses, the message is age-old—“don’t be arrogant.” Recognize that errors can happen and one may need the assistance of a colleague.

Although specific case examples discussed in this chapter are general surgical in nature, the major principles are applicable to all surgical specialties.

A word of caution for overly negative sentiments about our profession is necessary. With frequent media attention to how dangerous U.S. hospitals are, context becomes very important. The Centers for Disease Control and Prevention (CDC) estimates that 54 million surgical procedures were performed in 2010 alone. As a profession of surgeons, we are doing remarkably well if only 4000 “never events” occur out of 54 million cases. The goal is to render better care, not succumb to defeatism.

Additionally, many problems we encounter in the operating room are not “never events.” Wrong-site surgery, intraoperative death in a healthy patient, and retained objects garner significant media attention, but the reality is we are in a business where the combination of patient disease and anatomic variance often do not conform well to checklists and protocols.

Prevention and preparation are cornerstones of success in many fields; however, sometimes things simply go wrong despite our best efforts. I will share a few examples of rescue strategies for when things go awry during surgery and hope you can gather some useful tips for your practice.

Case Study 6.1

The hypothesis: Common bile duct injury is one of the most feared complications associated with laparoscopic cholecystectomy. When injury occurs, it is wise to seek experience and an objective assessment intraoperatively.

The story: A 46-year-old, obese, but otherwise healthy woman had symptomatic cholelithiasis for many months. She was fully evaluated and preoperative blood work did not reveal chemical signs of common bile duct obstruction. On the day of surgery, the responsible surgeon reviewed the surgical risks again in the preoperative holding bay. The patient was taken to the operating room and the anesthesiologist provided comfort to the patient by saying, “This surgeon does this hundreds of times a month, don’t worry.” Ports were placed and the surgery began uneventfully. There was significant scar tissue due to the chronicity of the symptoms; there was an acute on chronic component to the cholecystitis. The dissection was difficult but the cystic duct and cystic artery were meticulously and circumferentially isolated. The cystic duct was divided, but the surgeon quickly realized that there was another ductal structure posteriorly leading to the neck of the gallbladder. The surgeon panicked, continued dissecting the posterior ductal structure and subsequently divided the second ductal structure and the cystic artery. The gallbladder was removed and retrieved. The surgeon has never repaired a common bile duct injury before but recalled his experience performing a bilio-enteric anastomosis when he was on transplant rotation some years ago. He decided to convert to an open procedure and proceeded with the hepaticojejunostomy and left drains.

The patient’s outcome: Postoperatively, the patient was relatively stable initially, but quickly deteriorated due to biliary sepsis. Her liver function tests were increasing daily and the hospital had no interventional radiologist willing to provide biliary drainage; the only gastroenterologist capable of endoscopic retrograde cholangio-pancreatography was out of town. The surgeon decided to reexplore and noted a stricture at his anastomosis. This time, he inserted a T-tube just proximal to the stricture and replaced his drains. The patient was eventually transferred to a hepatobiliary service at another hospital and had a prolonged, surgical intensive care course.

What went wrong? The surgeon in this case did not recognize his own limitations. He performed a procedure with which he has little unsupervised experience. Additionally, he failed to call for a qualified intraoperative consultation. Due to his lack of experience, his decision to leave the primary repair without lateral T-tube drainage was poor judgment. Remember, this patient had chronic inflammation in this tenuous, high-risk anastomosis. An intraoperative cholangiogram should have been performed to ascertain variation in anatomy and the site of injury. In the recovery period, the surgeon did not appropriately assess the resources available at his institution and delayed an important transfer to a referral center. See Figure 6.1.

How to prevent this error in the future? The overall incidence of biliary injury is less than 1% in most series.⁵ Surgeon experience plays a significant role in biliary injury; the learning curve usually occurs under the watchful eyes of attending surgeons during residency. The first 30 to 50 cases carry the highest incidence of biliary injury. Recognition of the injury is paramount to successful outcome. The role of routine, intraoperative cholangiography in detecting or mitigating biliary injury is controversial.⁶ Despite several prospective randomized trials, the evidence is insufficiently powered to make definitive guidelines. The vast majority of injuries are not identified intraoperatively and one needs to have a high index of suspicion when the postoperative course is not “routine.” The key steps in management of biliary injury are: (1) recognition, (2) repair, and (3) recovery.

For discussion sake, assume that the biliary injury is detected intraoperatively. Recognition of an injured common bile duct can instantly induce a mind-numbing paralysis. Thoughts become disorganized and pressured; one surgeon I know describes the experience as suffering through all Kübler-Ross stages of grief in a few seconds.

Indeed, many of us have experienced this feeling and yet we have to carry on with surgery. Intraoperative stress intuitively impairs performance, but this is not universally so. Equipment failures, complex cases, early practice, and laparoscopic surgery all contribute to an increase in intraoperative stress. Although the literature is very heterogeneous, the implication is that stress (which is mitigated by experience) can contribute to poor patient outcome.

Aviation pioneer Louise Thaden is quoted as saying, “A pilot who says he has never been frightened in an airplane is, I’m afraid, lying.” Airline pilots are trained to handle emergency situations with razor sharpness and nerves of steel. For all the attention the airline industry gets for its impeccable safety record, its pilot preparation for unanticipated emergencies was called into question by NASA research psychologist Steve Casner. His article “The Effectiveness of Airline Pilot Training for Abnormal Events” elucidates the concept that we are usually well prepared for the “expected emergency.”⁷ Unfortunately, when faced with an unanticipated obstacle, as we occasionally encounter intraoperatively, pilots do not necessarily perform as effectively. Nevertheless, being well-versed in several rescue techniques is likely beneficial for unexpected emergencies as well. Our goal is to be in a state of clarity when faced with unforeseen obstacles.

What are some options for the recognized common bile duct injury intraoperatively? If you have the experience and technical ability to perform the repair, it will likely lead to a better outcome for the patient. Be honest with yourself and pose the following questions:

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   Are you in the best state of mind to perform the repair?

   
   
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   Is there someone more qualified to perform the repair than you?

   
   
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   Do you have a multidisciplinary team of interventional radiologist, gastroenterologist, and skilled nursing to support the perioperative period?

A candid assessment of not only one’s own skill repertoire, but that of others within the institution, is important because isolated management of a complex common bile duct injury can lead to significant morbidity for the patient. Primary repair (placing sutures to close a ductotomy) is rarely advised because of high stricture rate so the repair generally requires an advance biliary-enteric procedure.

If repair is to be performed at the index operation, the recommendation is to perform a biliary-enteric anastomosis over a lateral T-tube drainage. Primary repair of a ductal disruption has prohibitive stricture rate and subsequent morbidity of up to 30%.⁸ This repair should be performed by an experienced surgeon at your institution. Some argue that surgeons should not offer surgeries for which they cannot fix the complications; however, few of us operate in vacuums. When more qualified individuals are available, they should perform the repair at the index operation to offer the patient the best chance of a good outcome.⁹ See Figure 6.2.

If you feel uncomfortable with the repair, or no qualified surgeon is available, the main goal is to achieve biliary drainage and transfer the patient. Biliary drainage can be achieved with simple T-tube drainage, placed through a separate ductotomy. Alternatively, if surgical drainage cannot be achieved, one can ask interventional radiology or gastroenterology to perform antegrade or retrograde drainage, respectively. If no interventionalist or gastroenterologist is available, it is wholly acceptable to achieve temporary abdominal closure for transfer to a higher level of care with necessary resources. See Figure 6.3. The caveat is biliary drainage needs to be arranged upon arrival to the new hospital. Advanced Trauma Life Support (ATLS) espouses the teaching of stabilize and transfer, so as to not delay necessary care and to not increase chances of secondary injury. As is the case with trauma patients who overwhelm local resources, no additional procedures should be undertaken on the biliary injury patient before initiating referral to a tertiary center.