Measuring Outcomes of Clinical Care: Victorian Emergency Laparotomy Audit Using Quality Investigator.

BACKGROUND: The Australian and New Zealand Audit of Surgical Mortality (ANZASM) National Report 2015 found that within the cohort of audited deaths, 85% were emergencies with acute life-threatening conditions, and by far, the most common procedures were laparotomy and colorectal procedures. Emergency laparotomy outcomes have shown improvement through audit and reporting in the UK. The purpose of this study was to determine the outcome of emergency laparotomy in the state of Victoria, Australia. METHOD: The Dr Foster Quality Investigator (DFQI) database was interrogated for a set of Australian Classification of Health Intervention (ACHI) codes defined by the authors as representing an emergency laparotomy. The dataset included patients who underwent emergency laparotomy from July 2007 to July 2016 in all Victorian hospitals. RESULTS: There were 23,115 emergency laparotomies conducted over 9 years in 66 hospitals. Inpatient mortality was 2036/23,115 (8.8%). Mortality in the adult population increased with age and reached 18.1% in those patients that were 80 years or older. 51.3% were females, and there was no significant difference in survival between genders. Patients with no recorded comorbidities had a mortality of 4.3%, whereas those with > 5 comorbidities had 19.3% mortality. CONCLUSION: Administrative data accessed via a tool such as DFQI can provide useful population data to guide further evidence-based improvement strategies. The mortality for emergency laparotomy within Victorian hospitals is comparable, if not better than that seen in overseas studies. There is a need to continue routine audit of mortality rates and implement systems improvement where necessary.

Measuring the Burden of Surgical Disease Averted by Emergency and Essential Surgical Care in a District Hospital in Papua New Guinea.

BACKGROUND: Timely access to emergency and essential surgical care (EESC) and anaesthesia in low- and middle-income countries (LMICs) prevents premature death, minimises lifelong disability and reduces their economic impact on families and communities. Papua New Guinea is one of the poorest countries in the Pacific region, and provides much of its surgical care at a district hospital level. We aimed to evaluate the surgical capacity of a district hospital in PNG and estimate the effectiveness of surgical interventions provided. METHODS: We performed a prospective study to calculate the number of DALYs averted for 465 patients treated with surgical care over a 3-month period (Sep-Nov 2013) in Alotau Hospital, Milne Bay Province, PNG (pop 210,000). Data were also collected on infrastructure, workforce, interventions provided and equipment available using the World Health Organization's Integrated Management of Emergency and Essential Surgical Care Toolkit, a survey to assess EESC and surgical capacity. We also performed a retrospective one-year audit of surgical, obstetric and anaesthetic care to provide context with regards to annual disease burden treated and surgical activity. RESULTS: EESC was provided by 11 Surgeons/Anaesthetists/Obstetricians (SAO) providers, equating to 5.7 per 100,000 population (including 4 nurse anaesthetists). They performed 783/100,000 procedures annually. Over the 3-month prospective study period, 4954 DALYs were averted by 465 surgical interventions, 52 % of which were elective. This equates to 18,330 DALYs averted annually or, approximately 18 % of the published but estimated disease burden in the Province in the 2013 Global Burden of Disease Study. The overall peri-operative mortality rate was 1.29 %, with 0.41 % for elective procedures and 2.25 % for emergencies. CONCLUSIONS: Much of the burden of surgical disease in Papua New Guinea presenting to Alotau General Hospital serving Milne Bay Province can be effectively treated by a small team providing emergency and essential surgical care. This is despite a relatively low surgical volume and limited numbers of trained surgical anaesthesia obstetric providers, and likely underservicing. The ability of surgical care to avert disease in Papua New Guinea highlights its importance to public health in LMICs.

Systematic review and meta-analysis of hepatic resection versus transarterial chemoembolization for solitary large hepatocellular carcinoma.

BACKGROUND: Surgical techniques and pre-operative patient evaluation have improved since the initial development of the Barcelona clinic liver cancer staging system. The optimal treatment for solitary hepatocellular carcinoma ≥5 cm remains unclear. The aim of this study was to review the long-term survival outcomes of hepatic resection versus transarterial chemoembolisation (TACE) for solitary large tumours. METHODS: EMBASE, MEDLINE, Pubmed and the Cochrane database were searched for studies comparing resection with TACE for solitary HCC ≥5 cm. The primary outcome was overall survival at 1, 3 and 5 years. RESULTS: The meta-analysis combined the results of four cohort studies including 861 patients where 452 underwent hepatic resection and 409 were treated with TACE to an absence of viable tumour. The pooled HR for 3 year OS rate calculated using the random effects model was 0.60 (95% CI 0.46-0.79, p < 0.001; I2 = 54%, P = 0.087). The pooled HR for 5 year OS rate calculated using the random effects model was 0.59 (95% CI 0.43-0.81, p = 0.001; I2 = 80%, P = 0.002). CONCLUSION: Hepatic resection has been shown to result in greater survivability and time to disease progression than TACE for solitary HCC ≥5 cm. Where a patient is fit for surgery, has adequate liver function and a favourable tumour, resection should be considered.

Mapping timely access to emergency and essential surgical services: The Malaysian experience.

BACKGROUND: Surgical conditions form a significant proportion of the global burden of disease. Since the 2015 World Health Assembly resolution A68.15, there is recognition that the provision of essential surgical care is an integral part of universal access to health care. The Lancet Commission on Global Surgery proposed its first surgical indicator to measure a population's access to the Bellwether procedures (laparotomy, caesarean section and treatment of open fracture) within two hours. Bellwether access is a proxy for emergency and essential surgical care. This project aims to map essential surgical access to the Bellwether procedures in Malaysia. METHODS: The location and capability of hospitals to perform the Bellwether procedures was obtained from the Ministry of Health (MoH) and MoH hospital specific websites. The Malaysian population data were retrieved from the national department of statistics. Times for patients to travel to hospital were calculated by combining manual contouring and geospatial mapping. RESULTS: There were 49 Bellwether-capable MoH hospitals serving a national population of 32.5 million. Overall 94% of Malaysia's population have access to the Bellwethers within two hours. This coverage is universal in West (Peninsular) Malaysia, but there is only 73% coverage in East Malaysia, with 1.8 million residents of Sabah and Sarawak not having timely access. Malaysia's Bellwether capacity compares well with other countries in World Health Organisation's Western Pacific region. CONCLUSION: There is good access to essential and emergency surgical services in Malaysia. The incomplete access for 1.8 million people in East Malaysia will inform national surgical planning.

Short-term outcomes of pancreaticoduodenectomy in the state of Victoria: hospital resources are more important than volume.

BACKGROUND: Pancreaticoduodenectomy (PD) is a high-risk procedure. Australian hospitals perform a relatively low volume of PD. This study sought to gain an understanding of hospital volume and short-term outcomes of the procedure in the Australian state of Victoria. METHODS: The Dr Foster Quality Investigator tool was used to interrogate the Victorian Admitted Episodes Database for the Australian Classification of Health Intervention code for PD (30584) from July 2010 to June 2016. The data set included patients from a peer group of 14 hospitals that included all the public hospitals performing PD during this period. Patient characteristics, inpatient mortality, 30-day readmission rates and median length of stay were reported for each de-identified hospital. RESULTS: There were 547 PD conducted over 6 years in 10 public hospitals. The median patient age was 65 years. Inpatient mortality was 2.7%. There was a significant risk adjusted difference in mortality between principal referral and other public hospitals. Annual hospital volume ranged from 3 to 20 PD, and there was no significant relationship between mortality, readmission rates or length of stay and hospital volume. CONCLUSION: The inpatient mortality associated with PD in Victorian public hospitals is comparable to that seen in overseas studies. While hospital volume is relatively low, there does not seem to be a relationship between volume and short-term outcomes. Variability between hospital peer groups suggests that resource availability is more important than volume. The development of a procedure specific registry would be useful to test the outcomes of this study and determine long-term PD outcomes.

State-wide outcomes in elective rectal cancer resection: is there a case for centralization in Victoria?

BACKGROUND: The role of service centralization in rectal cancer surgery is controversial. Recent studies suggest centralization to high-volume centres may improve postoperative mortality. We used a state-wide administrative data set to determine the inpatient mortality for patients undergoing elective rectal cancer surgery and to compare individual hospital volumes. METHODS: The Victorian Admitted Episodes Dataset was explored using the Dr Foster Quality Investigator tool. The inpatient mortality rate, 30-day readmission rate and the proportion of patients with increased length of stay were measured for all elective admissions for rectal cancer resections between 2012 and 2016. A peer group of 14 hospitals were studied using funnel plots to determine inter-hospital variation in mortality. Procedure types were compared between the groups. RESULTS: There were 2241 elective resections performed for rectal cancer in Victoria over 4 years. The crude inpatient mortality rate was 1.1%. There were no significant differences in mortality among 14 hospitals within the peer group. The number of elective resections over 4 years ranged from 14 to 136 (median 65) within these institutions. Ultralow anterior resection was the commonest procedure performed. CONCLUSION: Inpatient mortality after elective rectal cancer surgery in Victoria is rare and compares favourably internationally. Based on inpatient mortality alone, there is no compelling evidence to further centralize elective rectal cancer surgery in Victoria. More work is needed to develop data sets with oncological information capable of providing accurate complete state-wide data which will be essential for future service planning, training and innovation.

Loch ness, special operations executive and the first surgeon in paradise: Robert Kenneth Wilson (26.1.1899-6.6.1969).

Lieutenant Colonel Robert Kenneth Wilson (1899-1969) was a surgeon who fought in both world wars and joined the Special Operations Executive parachuting behind enemy lines into Holland, France and Borneo, the last mission being with Australian forces (Semut II). He was an expert on firearms and gave opinion on ballistics at the Old Bailey during the 1930s. He also wrote a definitive text on automatic pistols with editions published in 1943 and 1975. He was an Edinburgh Fellow (1926), who had a practice in general surgery and gynaecology in Queen Anne Street during the 1930s. He took the famous 1934 'surgeon's photo' of the Loch Ness monster that was not admitted to be a hoax until 1994. After World War II, he became the first surgical specialist to work in the public service of the then Territory of Papua and New Guinea (1950-1956), where he wrote several papers on surgical topics. He married Gwen (1924), the daughter of Henrietta Gulliver, an Australian painter. They had two sons, Richard and Phillip. After practice he retired to Melbourne where he died of carcinoma oesophagus.

Thyroid surgery in the tropics.

In the tropics thyroid surgery is carried out either by general surgeons or ear, nose and throat surgeons and there are few places with a subspecialist endocrine or head and neck surgeon. The aim of this review is to determine the pattern of thyroid pathology, surgery and surgical outcomes in the tropics. A review of thyroid surgery in tropical regions was carried out based on published articles in English in Medline (1965-2004). The findings are also discussed in the light of the authors' own experience of thyroid disease and thyroid surgery in four continents. The pattern of thyroid pathology varies in the tropics, particularly in regions where endemic goitre is common. Endemic goitre usually regresses with iodine therapy. There is a rising incidence of thyroid autoimmune disease, particularly Graves' disease and Hashimoto's thyroiditis, probably related to an environmental immunological stimulus associated with development. Surgery is indicated for the same reasons as in the developed countries: thyrotoxicosis (more often in the absence of radioactive iodine therapy), solitary thyroid nodule and multinodular or malignant goitre. However, a preoperative cytological diagnosis will only be available in important centres where there is a pathologist. Malignancy appears more prevalent in nodules and goitres in the tropics than in the developed countries, perhaps because patients with malignancy are more likely to be referred to a surgeon. Nonetheless, the evidence suggests that thyroid surgery can be carried out safely with a minimum of complications even in remote mission hospitals with limited facilities for investigation. Standards can be set in terms of surgical outcomes; for example, mortality (0%), permanent recurrent laryngeal nerve (RLN) injury (<2%), re-exploration for haematoma(<2%), permanent hypocalcaemia (<5%) and wound infection (2.5%). The choice of operation depends on the local pathology and the likelihood of being able to obtain lifelong thyroxine. Total thyroidectomy should be avoided whenever possible if thyroxine supplies are unreliable. Advanced thyroid cancer presents a therapeutic challenge and some cases will be unresectable. The management options are limited by the resources available. Similar surgical outcomes should be able to be achieved no matter where the surgery is carried out.

Skull trepanation in the Bismarck archipelago.

BACKGROUND: Skull trepanation is an ancient art and has been recognized in many, if not most, primitive societies. Papua New Guinea came into contact with Europeans in the late 1800s and therefore it was possible for the art to be documented at a time when cranial surgery in Europe was still in its infancy. METHODS: A reviewof published articles and accounts of those who observed skull trepanation or spoke to those who had. Review of a video of trepanation as practised today in Lihir. FINDINGS: Richard Parkinson was a trader turned amateur anthropologist who was able to observe the surgical procedure being practised in Blanche Bay (New Britain). Trepanation was also witnessed by Rev. J.A. Crump in the Duke of Yorks. In New Britain the operation was performed for trauma but in New Ireland it was also employed on conscious patients for epilepsy or severe headache, particularly in the first five years of life. There was, however, a tendency to operate on frontal depressed and open fractures, rather than temporoparietal ones. Once the decision to operate was made the wound was irrigated in coconut juice and this was also used to wash the hands of the surgeon. Anaesthesia was not required as the traumatized patient was unconscious. The procedure is described and the tools included local materials such as obsidian, shark's tooth, a sharpened shell, rattan, coconut shell and bamboo. Of particular interest is the observation of brain pulsations and their relationship to a successful outcome. ASSESSMENT: The outcomes were good, in that 70% of patients were thought to survive, contrasting with a 75% mortality for cranial surgery in London in the 1870s. There is supporting evidence in that many trepanned skulls show evidence of healing and life long after the procedure was completed. Other societies have reported similar survival rates. The good outcomes may have been due to wise case selection as well as a high level of surgical skill following sound principles of wound debridement without necessarily being able to drain a haematoma.

Colorectal multidisciplinary meetings: how do they affect the timeliness of treatment?

BACKGROUND: The aim of this study is to determine whether multidisciplinary team (MDT) meetings alter the length of time to treatment (LOTT) for patients with colorectal cancer. METHODS: We conducted a retrospective audit of all patients with colorectal cancer from the Geelong Hospital (TGH) mandatory colorectal database from 1 January 2006 to 3 February 2011. To be included, patients had to have had elective surgical intervention for primary colorectal adenocarcinoma. A comparison of historical controls was conducted between patients discussed in MDT meetings and those managed prior to the introduction of MDT meetings (3 October 2006) to determine the LOTT in days from definitive diagnosis (colonoscopy) to definitive management (surgery, radiotherapy or chemotherapy). RESULTS: In total, the median LOTT for the historical control and MDT era patient populations were 19.5 and 20 days, respectively. Within the MDT era, we noticed significantly longer times to treatment for patients with rectal cancer who were seen in an MDT meeting prior to definitive management than patients who did not have an intervening MDT meeting (P < 0.001). With a difference of 7.5 days, the clinical significance of these findings remains contentious. However, it is worthwhile recognizing this trend in patients who are exhibiting symptoms due to near obstruction or significant bleeding. The LOTT for colon cancer patients remained unchanged. CONCLUSION: The introduction of MDT meetings to TGH has prolonged the LOTT for patients with rectal cancer. These findings pave the way for further revision of the efficiency of MDT meeting at TGH.

Specialist surgical training in Papua New Guinea: the outcomes after 10 years.

Surgical training commenced in 1975, the year that Papua New Guinea (PNG) gained independence. The training involves a 4-year programme leading to a Master of Medicine (MMed), awarded by the University of Papua New Guinea. In the past 30 years just over 50 general surgeons have graduated. There have also been 9 graduates in the area of ear nose and throat, 10 in ophthalmology and 2 in oral surgery. The subspecialization of general surgeons began in 1994 with four trainees, two orthopaedic, one head and neck and one urological. The model used was to develop specialist skills over 2-3 years only qualified (MMed) general surgeons so that their ability to carry out general surgical procedures and work in a remote hospital was not lost. The different specialties required different balances of in-country and out-of-country training depending on the local ability to provide training in PNG. An important sponsor has been the PNG National Department of Health, which has funded the training posts by using existing general surgical positions and covering the loss of manpower while surgeons are training overseas, sometimes for up to 2 years. Medical education and tertiary health service projects, funded by Aus-Aid, have also contributed significantly to the teaching and training. These projects have provided visiting specialists to teach and hospital attachments for national surgeons to train in Australasia. Various individual surgeons and their specialist societies in Australasia have also provided invaluable support. Three surgeons have been recipients of the Rowan Nicks scholarship. Twelve surgeons have been awarded a specialist diploma and a further five are in training. The posting of national specialist surgeons to Port Moresby has resulted in all modules of the General surgery MMed programme being taught by Papua New Guineans, which would have been hard to imagine back in 1993. The MMed is now a sustainable programme and can be provided without external support. National surgeons carry out a wide range of specialist procedures, formerly carried out only by visiting teams. They are also able to make outreach visits within PNG and specialist visits to neighbouring Pacific Island countries.

Guidelines for surgical audit in Australia and New Zealand.

Surgical audit is an important part of the process to measure performance, reduce clinical risk and improve quality of care. Recognizing this, the Royal Australasian College of Surgeons established a Surgical Audit Taskforce as a subcommittee of the Board of Continuing Professional Standards. This study aims to review the recommendations of the Taskforce for data collection and peer review. The minimum data for whole-practice, continuing audit have been defined. The method of data collection, devices and databases are personal choices for the individual surgeon. However, there are many benefits of developing an electronic surgical audit, and these include facilitating comparison and sharing of audit data between units. Surgical audits should not only report on work carried out but also ensure that outcomes include key performance indicators such as major complications, readmissions, reoperations, transfers, incident reports, complaints and mortalities. Effective clinical governance demands that issues raised by audit need to be documented and reported together with recommendations for improvement. Surgeons should be proactive in helping to find and implement solutions to the issues arising from surgical audit.

Requirements for trainee logbooks.

All trainees are required to keep a logbook as a record of the procedures they have carried out during their surgical training. However, the current logbook is only a record of work carried out and not of the outcome of the operations. It does not prepare the trainee for either a lifetime practice of surgical audit or for a lifetime of learning from the audit process. The logbook requirements of different training boards vary and consequently, trainees find the keeping of a logbook an inconsistent process with ill-defined learning objectives. The Royal Australasian College of Surgeons should define what needs to be collected, how data should be verified and how experience and learning should be reported, and should approve electronic databases that meet logbook standards. The choice of database software and format can then be left to the trainee. Although there are good examples of electronic logbooks being developed, there is, at present, no perfect logbook available. We recommend that all trainees, from the commencement of basic surgical training, should keep a logbook that contains the minimum and expanded datasets in addition to specific trainee data on supervision and learning. In addition to the current reporting format focused on procedural casemix and supervision level, quality/outcome reports and a record of learning are recommended.

The surgical trainee log we need: minimum of work, maximum of output.

BACKGROUND: The objective of this study was to design a trainee logbook suitable for both surgical training and surgical audit. The fields of the logbook should conform to both the current requirements for surgical trainee logbooks and the minimum and recommended datasets for surgical audit. The database should be able to share information with other databases including hospital information systems. The current logbook requirements do not include much outcome data. Therefore, keeping the logbook does not train the young surgeon to collect all the information necessary for surgical audit, particularly the recently promoted minimum (12 fields) and recommended (22 fields) datasets. METHODS: An electronic logbook was developed as part of the hospital's clinical information system (CORDis). Patient identifier information was available in the system and did not need to be re-entered (e.g. name, number, date of birth and sex). The trainee only input the necessary fields for his/her logbook and was able to derive information already available from CORDis on complications, outcome and final diagnosis of the patient. RESULTS: Thirteen of 16 trainees used the program over a period of 2.5 years, and more than 4600 operative procedures were recorded. Information on outcome and complications was included in the logbook, regardless of who in the team entered the data. This also facilitated surgical audit presentations. Logbook reports for the Advanced Training Board were produced with the click of a mouse rather than by spending a whole weekend counting items in the operation register at the end of a 6-month rotation. This system could be used at different hospitals or the data can be exported to another database including databases on a hand-held device. CONCLUSION: The logbook contains all the data for reporting to the Specialty Training Board and Surgical Audit. Duplication of data entry was reduced, and presentation of unit/trainee surgical audits was facilitated. The data can be exchanged with other common databases when the trainee rotates out of Geelong.

Influence of training on the family.

BACKGROUND: There is currently a shortage of surgeons working in rural Australia. This may be due to partner dissatisfaction with rural placements during training. METHODS: A questionnaire encompassing logistic, financial and emotional aspects of peripheral placements was distributed to trainees and their partners. A similar questionnaire was also distributed to 25 rural surgical consultants. RESULTS: Seventy-four per cent of trainees were either married or in long-term relationships. A further 24% had children. The average number of residential moves per year of training was 0.74. Respondents reported difficulties that included accommodation suitability, general practitioner availability, financial burden and finding amenities such as school and crèches. Many (66%) partners had experienced high levels of isolation or loneliness, whereas some reported the development of a stress-related disorder, depression or anxiety. Most respondents indicated that their partner would influence their decision to work in a given location. Furthermore, 20% of consultant surgeons had either moved town or had seriously considered moving town because of their spouse or children's dissatisfaction. CONCLUSION: Training in peripheral locations causes significant stress to the trainee and their families. These experiences dissuade trainees from working in rural locations as consultants.

How Does Cholecystectomy Influence Recurrence of Idiopathic Acute Pancreatitis?

BACKGROUND: Idiopathic acute pancreatitis is diagnosed in approximately 10-30 % of cases of acute pancreatitis. While there is evidence to suggest that the cause in many of these patients is microlithiasis, this fact has not been translated into a resource efficient treatment strategy that is proven to reduce recurrence rates. The aim of this study was to examine the value of prophylactic cholecystectomy following an episode of acute pancreatitis in patients with no history of alcohol abuse and no stones found on ultrasound. METHODS: This was a retrospective study of 2236 patients who presented to a regional Australian hospital. Patients were included when diagnosed with acute pancreatitis with no confirmed cause. Recurrence of acute pancreatitis was compared between those that did and did not undergo cholecystectomy. RESULTS: One hundred ninety-five consecutive patients met the study definition of "idiopathic" acute pancreatitis. 33.8 % (66/195) underwent cholecystectomy. The patients who had cholecystectomy had a recurrence rate of 19.7 % (13/66) whereas, of those managed expectantly, 42.8 % (68/159) had at least one recurrence of acute pancreatitis (P = 0.001). CONCLUSIONS: Following an episode of acute pancreatitis with no identifiable cause, in patients fit for surgery, cholecystectomy should be considered to reduce the risk of recurrent episodes of pancreatitis.

Evaluation of the medium-term outcomes and impact of the Rowan Nicks Scholarship Programme.

BACKGROUND: Rowan Nicks was a cardiothoracic surgeon in Sydney. He endowed the Rowan Nicks Scholarship Programme of the Royal Australasian College of Surgeons, which was initiated in 1991 to provide opportunities for clinicians from developing countries so that they return to their countries as leaders and teachers. This paper's objective was to evaluate the outcomes and impact of the scholarship on individuals and their communities. METHODS: A survey was undertaken of 34 eligible scholars of whom 29 participated. It was directed at whether objectives were achieved in technical skills, patient management and in competency in research and leadership. RESULTS: Ninety-eight per cent of scholars returned to work in their home country. Twenty-eight of 29 were working in their chosen specialty and had returned to their former positions. The clinical/operative skills obtained were regarded as useful by 86%, and 22/29 (76%) scholars reported they had gained worthwhile leadership and administrative skills. Improved clinical outcomes for patients were achieved as evidenced by reduced mortality and less disability. There was also a positive impact on health systems. The best documented of these were improved trauma management, development of paediatric surgery in rural Bangladesh, a new cardiac unit in Myanmar, organ transplantation and better injury outcomes in Papua New Guinea. CONCLUSION: The programme has resulted in potential and actual leaders returning to their home countries where they positively impacted on health and surgical services. This has resulted in a reduced burden of surgical disease in the scholars' countries as measured by less death, disability and deformity.

Guy de Chauliac: pre-eminent surgeon of the Middle Ages.

Guy de Chauliac (c1300-1368) trained in Toulouse and the University of Montpellier from where he achieved the highest possible degree of Master of medicine. He undertook fellowships in Bologna (anatomical dissection) and Paris (surgery) and was qualified as a physician not a Barber Surgeon. He took Holy Orders and was appointed as physician to three Avignon-based Popes. He survived an epidemic of the Black Death (1348-1350), suffering an axillary bubo. His book Chirugia Magna was written in medieval Latin in 1363, then circulated in manuscript form before its first printing in 1478. There were 70 editions as it became the most influential surgical text for over 200 years, particularly in France, spanning the period from the late 14th century until Paré (1510-1590). He divided surgery into swellings, wounds, ulcers, fractures and dislocations, and special diseases. Well researched and referenced, based on evidence and experience, he succeeded in incorporating antiquarian and contemporary thinking from French, Arabian, Italian (Bologna), Egyptian and Greek scholars about anatomy, surgical disease and treatment. He was a strong advocate for evaluating outcomes, knowing when not to operate, professionalism and the non-technical competencies. His framework of professionalism was based on four domains: being learned, expert, ingenious and adaptable. The surgical aspirants and leaders of the following two centuries recognized the academic, professional and practical value of his teaching through their reference to and use of Chirugia Magna. The Cowlishaw collection in the Royal Australasian College of Surgeons' library contains four French copies, under the title La Grande Chirugie.

Reducing errors in emergency surgery.

BACKGROUND: Errors are to be expected in health care. Adverse events occur in around 10% of surgical patients and may be even more common in emergency surgery. There is little formal teaching on surgical error in surgical education and training programmes despite their frequency. METHODS: This paper reviews surgical error and provides a classification system, to facilitate learning. The approach and language used to enable teaching about surgical error was developed through a review of key literature and consensus by the founding faculty of the Management of Surgical Emergencies course, currently delivered by General Surgeons Australia. RESULTS: Errors may be classified as being the result of commission, omission or inition. An error of inition is a failure of effort or will and is a failure of professionalism. The risk of error can be minimized by good situational awareness, matching perception to reality, and, during treatment, reassessing the patient, team and plan. It is important to recognize and acknowledge an error when it occurs and then to respond appropriately. The response will involve rectifying the error where possible but also disclosing, reporting and reviewing at a system level all the root causes. This should be done without shaming or blaming. However, the individual surgeon still needs to reflect on their own contribution and performance. CONCLUSION: A classification of surgical error has been developed that promotes understanding of how the error was generated, and utilizes a language that encourages reflection, reporting and response by surgeons and their teams.

Making decisions in emergency surgery.

BACKGROUND: Good decision making is essential in surgery. In an emergency, the time for decision making is often short, and the information available is incomplete. The way experienced surgeons make decisions is often not well understood, and therefore is difficult to teach to trainees. METHODS: This paper examines how decisions are made, based on recent literature and the experience of the authors and their colleagues. DISCUSSION: An accurate assessment precedes decision making, and is directed towards the patient, the personnel and environment. Studies of other high-stakes professions have highlighted the existence of two distinct mental processing symptoms. One is fast and frugal, relying on pattern recognition or following a rule or protocol. This is often performed at a subconscious level. The other is a conscious, reasoned, analytical process. This requires adequate, available mental capacity. In reality, expert and experienced decision makers can adopt either or both approaches, and match their approach to the situation. Decisions made need to be constantly reviewed, particularly where there is mismatch between what was anticipated and what is encountered. CONCLUSION: An algorithm of decision making in emergency surgery has been developed that is based on assessment, the decision required and the outcome of the decision. The decision must also consider the urgency of the situation and the likely outcome if the plan made fails.