Fighting human error : what surgeons can learn from aviators.

BACKGROUND: The rigorous implementation of safety policies have made air travel one of the safest modes of transport. Health institutions and hospital managing bodies increasingly adopt cues from aviation safety protocols and policies in an attempt to reduce medical errors and patient harm. Among hospital staff, surgeons are most likely to be confronted with these aviation-derived safety concepts. METHODS: This article aims to familiarize surgeons with the concepts and methodology of safety policies in modern aviation safety, many of which have been applied in the setting of surgery, or have potential to do so. We review the use of checklists, crew resource management, the sterile cockpit, blame free reporting and human fatigue. We discuss how these concepts can be translated to the operating room and illustrate their relevance through a comparative description of historical air accidents and surgical incidents from our own clinical experience. We also indicate relevant differences and similarities between flight crews and surgical teams and their respective infrastructures, as these may impede or facilitate the adoption of aviation safety policies. Finally, we offer some recommendations to effectively implement aviation safety policies in the operating room.

A retrospective study of 74 laparoscopic repairs of abdominal incisional hernias.

INTRODUCTION: A laparoscopic procedure is used more and more frequently to treat incisional hernia with the potential benefits of shorter hospitalisation and a decrease in postoperative pain. The purpose of this retrospective study was to analyse the results of the laparoscopic treatment of incisional hernia at our institution and to identify potential risk factors for recurrence. METHODS: The medical data (pre-operative, peri-operative, and postoperative) of patients who received a laparoscopic repair of their incisional hernia between January 2003 and February 2007 were recorded. The follow-up was based on a retrospective analysis of the information found in the patients' medical records. RESULTS: Seventy-four laparoscopic interventions were performed on 71 patients. Polyester implants with an average size of 412.16 cm2 were used to cover the hernia. The mean operative time was 76.8 +/- 55.6 min (range, 20 to 295 min) and the mean duration of post-operative hospitalisation was 3.75 +/- 2.3 days (range, 2 to 12 days). One breach in the small intestine (1.4%) (sutured with 3/0 silk thread) and 1 conversion to laparotomy (1.4%) for a voluminous incisional hernia occurred during surgery. The post-operative morbidity was 8.2%, the rate of long-term complications was 27%, and 13 recurrences (including 3 with complications) were noted (17.6%) during a mean follow-up of 13 months. There was no postoperative mortality. Recurrences were linked to the use of large meshes corresponding to large incisional hernia diameter (p < 0.05). CONCLUSION: Although the morbidity/mortality rates are acceptable, technical improvements must be found to reduce the recurrence rate, in particular for large incisional hernias.

Laparoscopic cholecystectomy for acute cholecystitis in the elderly: a retrospective study of 100 patients.

BACKGROUND: The objective of this retrospective study is to evaluate the use oflaparoscopic cholecystectomy in the treatment of acute cholecystitis in elderly patients, and to identify risk factors for mortality. METHODOLOGY: In this study we have included patients with acute cholecystitis aged 75 years and older. Patients were diagnosed after anatomical and pathological examination of an operative sample. We retrospectively examined 100 patients who underwent cholecystectomy between June 1991 and February 2007. Seventy-nine patients (79%) underwent laparoscopic cholecystectomy, 12 patients (12%) needed a conversion, and 15 patients (15%) were considered unfit to undergo a laparoscopic approach, due to their hemodynamic condition or for other reasons. RESULTS: American Society of Anesthesiologists Scores (ASA), inflammatory syndrome, length of postoperative stay, number of days in the Intensive Care Unit, local complications, and mortality rate are all significantly higher in the 'laparotomy and conversion'. There was not a significant difference in age or general complications between groups. The mortality risk factors include a high level of CRP, biliary peritonitis, emergency, and the necessity of laparotomy. CONCLUSION: Acute cholecystitis is a severe pathology in the elderly associated with a high rate of morbidity and mortality. Due to the mortality risk factors associated with acute cholecystitis, we recommend elective laparoscopic cholecystectomy for aged patients with symptomatic cholelithiasis, due to its low morbidity and mortality rates.

Management of sigmoid diverticulitis: a retrospective study of 268 patients.

BACKGROUND/AIMS: The therapeutic management of acute diverticulitis has evolved over the last years in favour of an initial conservative approach with laparoscopy rather than a primary anastomosis. We studied the management of sigmoid diverticulitis in the Digestive Surgical Unit to assess it in comparison to actual practice. METHODOLOGY: A retrospective review of patients admitted to our unit from January 1998 to June 2006 for diverticular disease. We divided the patients into 3 groups (Urgent Medical Group (UM), Urgent Surgical Group (US) and Scheduled Surgical Group (SS)), and analysed demographic data, the severity and recurrence of diverticulitis, pathology results, length of stay, morbidity and mortality. RESULTS: The mean age was 60.5+/-14.9 years. The overall mortality was 3% (14.5% for the Acute Surgical Group and 0 % for the Elective Surgical Group); overall morbidity 38.4%; the incidence of neoplasm 4.8% in urgent colectomies and 0.9% in scheduled colectomies. CONCLUSIONS: Based on our study and published reviews, we recommend elective colectomy after 2 recurrent episodes of acute diverticulitis, one episode of complicated acute diverticulitis managed conservatively, or if the patient is younger than 50 years-old. This approach would reduce the number of acute operations, which are associated with high morbidity and mortality.

Intestinal stoma in patients with spinal cord injury: a retrospective study of 23 patients.

BACKGROUND/AIMS: Among spinal cord injury patients, digestive disorders are frequent, chronic, and progressive. Constipation and fecal incontinence, the most common disorders, can severely affect the quality of life of patients with spinal cord injury (SCI). METHODOLOGY: For this retrospective study, we reviewed the medical records of spinal cord injury patients with an intestinal stoma formation and developed a questionnaire to assess patient quality of life. Between January 1, 1996, and December 31, 2005, 10 SCI patients had a stoma formation for constipation, 10 for wound management, and 3 for other causes. Most of these stomas were performed by laparoscopy, with no postoperative mortality. RESULTS: Postoperative morbidity was 26% at the general level, with a rate of 4% at the local level; morbidity reached 56% at longer follow-up. The average period of bowel dysfunction was 7.2 years. The average time per week spent on bowel management (bowel care and defecation time) was 6 h prior to stoma formation, but decreased to 1.5 h afterwards. Half of the questionnaire respondents reported an improved quality of life. CONCLUSIONS: A left colostomy is an effective and safe alternative for anorectal disorders among SCI patients. For a large percentage of patients, it ensures an improved quality of life.

Surgical resection for colon cancer: laparoscopic assisted vs. open colectomy.

BACKGROUND/AIMS: Laparoscopic surgery has been considered for more than a decade for treatment of colorectal cancer. Although its benefits in term of postoperative comfort and parietal preservation are commonly accepted, its efficiency to achieve proper oncologic resection and to prevent tumor recurrence are still debated. The purpose of this retrospective study is to compare results of a minimally invasive laparoscopic approach to these of open surgery for treatment of colorectal cancer. METHODOLOGY: From January 1st 1999 to September 30th 2004, 239 patients underwent colorectal cancer resections; 28 of these patients underwent surgery in an emergent context and were excluded from this study. Accurate follow-up was available for 165 of the 239 patients (69%). For the study, 165 patients were divided into 3 groups: 39 patients underwent a laparoscopically assisted surgery (L group), 120 patients underwent an open colectomy (O group) and 6 patients initially treated with a laparoscopic approach were converted to open colectomy (L/O group) (conversion rate: 8.8%). RESULTS: Sex ratio, mean age and A.S.A. score, as well as patients' past records were similar in the 3 groups. Histological staging was more often stages 3 and 4 in the O group (62.5%) comparing to the L group (41%) (p < 0.5). Mean operating time was slightly longerwhen a laparoscopically assisted approach was used. Overall early mortality rate of this study was 1.8%. Combined local and general overall morbidity rate was 36%. Overall incidence of anastomotic fistulae was 4% and reintervention rate during the early postoperative period was 8%. Postoperative ileus period was often longer for patients of the O group but without statistical significance. Mean duration of hospital stay was similar in the 3 groups. Data concerning surgical resection did not show any difference between groups. None of the patients experienced a metastatic skin settlement. Overall anastomotic stenosis rate was low (2%). The overall locoregional recurrence rate was 12%, without difference between the 3 groups. Forty-two percent of these recurrences were secondarily treated by curative surgery. Similar survival rates as well as oncological spreading frequencies were found. CONCLUSIONS: Results obtained when comparing minimal invasive laparoscopically assisted surgery to open procedure are similar and efficient.

Laparoscopic management of acute small bowel obstruction: a retrospective study on 156 patients.

BACKGROUND/AIMS: Laparoscopic treatment of small bowel obstruction (SBO) has been proposed in selected patients. This study reports an experience and tries to establish indications for laparoscopy. METHODOLOGY: 156 patients underwent laparoscopic or open approach for SBO. Demographics, clinical, biological, radiological and previous surgery were recorded. Obstruction causes, conversion rates and postoperative complications were retrospectively analyzed. RESULTS: Laparoscopic approach was undertaken for 96 patients (61%) and completed in 62 (65%), whereas 34 (35%) required conversion. 60 patients (39%) underwent a direct open approach. Mortality was 10% and morbidity 38%. Postoperative adhesion was the predominant etiology. Conversion rate and type of approach was directly influenced by cause of obstruction and type of previous surgery, but not by number of previous surgeries. Conversions and open approach increase morbidity, mortality, length of stay and return to transit. CONCLUSIONS: Laparoscopy is an elegant tool for management of selected patients with SBO. A single band of obstruction appearing after minor surgery appears to be a good indication for laparoscopy. Nevertheless, conversion rate and morbidity are still high. On the contrary, laparoscopy seems contraindicated for patients with prior history of major abdominal surgery, neoplasia or multiple laparotomies, and a direct open approach is then advocated. Prospective randomized studies comparing laparoscopy and open approach are required to evaluate their respective efficacy and safety in management of SBO.

Long-term results of a non-ramdomized prospective mono-centre study of 1000 laparoscopic totally extraperitoneal hernia repairs.

BACKGROUND: Information concerning short-term results for laparoscopic extraperitoneal hernia repair is available, but long-term results remain poorly documented. The purpose of this non-randomized prospective study was to evaluate recurrence and chronic pain after hernia repair over a period longer than 10 years. MATERIALS AND METHODS: From 1995 to 2004, all patients aged 30 years or more, manifesting with inguinal hernia, were included in our study. Patients aged 20 to 30 years presenting with bilateral hernia, recurrent hernia, or who were heavy workers were also included. Patients who had pelvic irradiation, strangulated hernia, prostatic cancer resection, or a contra-indication to general anaesthesia were excluded. Of 1096 hernia repairs performed, 248 patients were excluded and underwent open repair and 848 patients (77.4%) were included in our prospective study, which corresponded to 1000 laparoscopic hernia repairs. RESULTS: The sex ratio (male : female) was 5:8, and the average age was 56 years. Seven hundred and fifty-three hernias (75.3%) were first repairs, 247 (24.7%) were recurrent hernias, and 161 were bilateral hernias. There were no mortalities. The conversion rate was 1.1%, and the global postoperative morbidity rate was 10.3%. Average follow-up was 39 months in 92.2% of the patients. Hernia recurrence rate was 1.5%. Chronic pain occurred in 2.9%. During this follow-up, 22 contra-lateral hernias appeared in those patients who initially had unilateral hernia repair (3.2%). All of these contra-lateral hernias could be successfully treated using a laparoscopic total extraperitoneal approach. CONCLUSIONS: The long-term results of this study demonstrate that preperitoneal laparoscopic hernia repair is a safe technique with a very low recurrence rate and low prevalence of chronic pain.

Abdominal surgery during pregnancy: a retrospective study of 23 patients.

OBJECTIVE: The aim of this study was to demonstrate that during pregnancy a large variety of non-gynaecological abdominal pathologies can be safely managed with surgery. METHODS: The medical records of twenty-three patients that were pregnant and underwent open or laparoscopic surgery from 1997 to 2007 were reviewed. RESULTS: Twenty-one of the 23 patients have given birth and all but one of the babies were healthy with normal weights, sizes, and APGAR scores. One patient had spontaneous termination of pregnancy one week after the surgical procedure and one patient is out of follow-up. Preterm partus was induced in three patients due to life-threatening conditions for the mother. Each laparoscopy was performed safely without peri-operative complications. CONCLUSION: Open or laparoscopic abdominal surgery poses little or no additional risk for mother or child.

Laparoscopic cholecystectomy; a retrospective 10-year study.

BACKGROUND/AIMS: To evaluate results of laparoscopic cholecystectomies realized in our department and to compare results concerning local and general complications with those reported in the literature. METHODOLOGY: We analyzed retrospectively all the 1255 laparoscopic cholecystectomies realized in our department between January 95 and December 2004. Local and general complications were analyzed. Mean age was 55.6 (21-94) years, sex ratio (F/M) was 3.9. Common bile duct stones were extracted by endoscopic retrograde endoscopy (ERCP) before surgery or by choledochotomy (less than 1% of cases). The operation was performed with 4 trocars, as described by Dubois. RESULTS: Conversion rate was 1.95%. Mean postoperative hospitalization duration was2.7 days. Morbidity was 5.8% with equal repartition between local and general complications. Therevere 2 common bile duct injuries (0.16%). Six patients suffered from residual bile duct stone after cholecystectomy; 5 were treated by ERCP and 1 by choledochotomy. Three patients died (0.24%) after general complications. CONCLUSIONS: Laparoscopic cholecvstectomv is a common operation with potential possible dramatic complications. We think that a radiological study of the biliary tract must be performed before surgery to avoid mistakes during the operation.

Laparoscopic nissen's fundoplication: retrospective study of 168 cases, long-term follow-up.

BACKGROUND/AIMS: Laparoscopic anti-reflux surgery has shown its efficiency since its description by B. Dallemagne in Belgium and T. Geagea in Canada in 1991. As encountered in the laparotomic approach, this technique can be associated with mid- and long-term postoperative side effects. METHODOLOGY: A retrospective study about 168 patients operated for a gastro-esophageal reflux using the Nissen's technique with division of the short gastric vessels through a laparoscopic approach. There were 73 men (43%) and 95 women (57%) with a median age of 44 years (mean: 54 years, range: 17-82). The patients were seen 10 days, one month and three months postoperatively. After one year, they were seen or contacted by phone. The mean follow-up duration was 19.8 months (median: 12 months, range: 0.33-132). RESULTS: The mean operation time was 109 minutes (range: 57-210). There was no death. The postoperative morbidity rate was 5%. 142 patients (84%) had a third month control gastroscopy. 123 patients (86.6%) didn't report any complaint related to their reflux after 3 months. After one year, 166 patients (98.8%) were contacted. A reflux recurrence was reported by 4 patients (2.4%), 157 (94.2%) had no complaints. Our results are similar to those found in the literature published about laparoscopic anti-reflux surgery. In our series, we noted less mechanical complications than in the literature. The choice of the technique and the characteristics of our patients could explain this difference. CONCLUSIONS: The laparoscopic total fundoplication with division of the short gastric vessels is, for most of the authors, the first choice technique in the surgical treatment of the gastro-esophageal reflux.

Spontaneous rupture of the spleen in relation to a non-Hodgkin lymphoma.

A 35-year-old man was admitted for surgery with complaints of left upper abdominal quadrant pain, tachycardia and hypotension with no history of trauma. A splenomegaly had just been diagnosed one week before, during, the work up for asthenia. An immediate CT scan revealed an intraperitoneal haemorrhage with splenic rupture. During emergency laparotomy, a splenic rupture was found and a splenectomy was performed. Histopathology of the spleen confirmed the diagnosis of a non-Hodgkin lymphoma.

Electrical activity in the rectum of anaesthetized dogs.

There is limited data available on the electrical activity of the rectum. An in vivo canine model was developed to record 240 extracellular electrograms simultaneously from the serosal surface of the rectum thereby enabling an off-line reconstruction of the behaviour of the electrical signals. Serosal rectal electrical activity is characterized by brief bursts of action potentials (=spikes) with a frequency of 22 cycles min(-1). High-resolution mapping of these signals revealed predominant propagation of these spikes in the longitudinal direction, originating from any site and conducted for a limited time and length before stopping spontaneously, thereby describing a patch of activity. The dimension of the patches in the longitudinal direction was significantly longer than the transversal width (13.6 vs 2.4 mm; P < 0.001). Spike propagation could occur in the aboral (46% of cases), in the oral (34%) or in both directions (20%). A bolus of betanechol (i.v., 0.5 mg kg(-1)) increased the frequency of the spikes without affecting size, shape or orientation of the patches. As in other parts of the gastrointestinal system, individual spike propagation in the rectum is limited to small areas or patches. The contractile activity of the organ could possibly reflect this underlying pattern of electrical behaviour.

Mapping slow waves and spikes in chronically instrumented conscious dogs: implantation techniques and recordings.

Myoelectric recordings from the intestines in conscious animals have been limited to a few electrode sites with relatively large inter-electrode distances. The aim of this project was to increase the number of recording sites to allow high-resolution reconstruction of the propagation of myoelectrical signals. Sets of six unipolar electrodes, positioned in a 3x2 array, were constructed. A silver ring close to each set served as the reference electrodes. Inter-electrode distances varied from 4 to 8 mm. Electrode sets, to a maximum of 4, were implanted in various configurations allowing recording from 24 sites simultaneously. Four sets of 6 electrodes each were implanted successfully in 11 female Beagles. Implantation sites evaluated were the upper small intestine (n=10), the lower small intestine (n=4) and the stomach (n=3). The implants remained functional for 7.2 months (median; range 1.4-27.3 months). Recorded signals showed slow waves at regular intervals and spike potentials. In addition, when the sets were positioned close together, it was possible to re-construct the propagation of individual slow waves, to determine their direction of propagation and to calculate their propagation velocity. No signs or symptoms of interference with normal GI-function were observed in the tested animals. With this approach, it is possible to implant 24 extracellular electrodes on the serosal surface of the intestines without interfering with its normal physiology. This approach makes it possible to study the electrical activities of the GI system at high resolution in vivo in the conscious animal.

Evolution during half a century of the results of digestive surgery in geriatric patients. A review of the literature, experience at C.H.U. Brugmann and the medium term outlook.

The undertaking of complex and major surgical procedures on frail elderly patients with multiple disorders has always been and still remains a controversial and enigmatic issue. At the same time, in an increasingly ageing society, the need for such procedures will extend and patients will expect a more favourable outcome. Surgery in old age will, therefore, pose an ongoing challenge. With better anaesthetic management, surgical techniques and comprehensive geriatric assessment, the overall results for all surgery have improved remarkably over the last few decades. Stringent pre-operative assessment and rigorous post-operative care have achieved a significant reduction in mortality and morbidity; surgery has become a lot safer.

[Ovarian metastasis and lung adenocarcinoma: a case report]. / Métastase ovarienne et adénocarcinome pulmonaire: observation d'un cas clinique.

Ovarian metastasis as first dissemination site of a lung adenocarcinoma has not been described in the literature. We report the case of a 61-year-old woman who had a pneumectomy for a centrally located lung adenocarcinoma, which was discovered on a routine chest X-Ray. During the follow-up, a Positron Emission Tomography (PET)-Scan showed a hypercaptation in the pelvic region. Abdominal CT-scan confirmed the presence of a mass which was compatible with a primary ovarian tumor. The patient underwent a hysterectomy and bilateral salpingo-oophorectomy. Pathology reported an adenocarcinoma. Immunohistochemical staining revealed cells expression for Thyroid Transcription Factor 1 (TTF-1), cytokeratin 7 (CK-7) and focally cytokeratin 20 (CK-20). Clinical course, pathological and immunohistochemical data concluded to the diagnosis of ovarian metastasis of the lung adenocarcinoma. In conclusion, in the differential diagnosis of an ovarian metastasis, clinicians should not forget the lung as primary site since epidemiologic data of lung cancer in women show progressive incidence.

Surgical management of acute perforation of peptic ulcers. A single centre experience.

INTRODUCTION: Acute perforation may occur in gastric and duodenal ulcers. During the past decade, the need for elective operation for peptic ulceration has decreased as medical treatment has improved. However, emergency operations for acute complications such as perforation or bleeding remain constant. Actually, the treatment of choice is simple suture-closure, with or without omentoplasty, and peritoneal lavage or even omentoplasty alone, associated with a high intravenous dose of inhibitors of the proton pump and Helicobacter pylori eradication, if needed. PATIENTS AND METHOD: The standard treatment in our team is to perform a peritoneal lavage and drainage and a simple closure of the ulcer with an omentoplasty. A first retrospective analysis was made on data collected from 1996 to 2001 and we completed a prospective study from 2001 to 2003 to compare our results with our old data and with data collected from other teams. RESULTS: The mean age and the mean ASA score were similar in the two groups. For the majority of the patients, the diagnosis was made from symptoms and the presence of free abdominal air. The delay between arrival in the emergency room and the operating room was significantly shorter in the second group, but operating time was longer in this group. Morbidity was more frequent in the first group but mortality remained quite similar. Our results indicate that in a trained team the morbidity has decreased as the delay in surgery decreased and that the rate of diagnosis on plain abdominal film has increased. Laparoscopic suture of a perforated peptic ulcer is as safe as the open procedure but allows the surgeon to search for another cause of free air and offers the possibility, if conversion is needed, to perform a shorter laparotomy.

A survey of Belgian anesthesiologists.

From this national survey, it appears that anesthesiologists work on average 60 hours per week in a hospital; male anesthesiologists an average of 11 percent more than their female colleagues. Age had no major conflict on the average working hours: recently qualified anesthesiologist are fully integrated into the work schedule from the very start; weekly working hours remain virtually unchanged until the age of sixty and then gradually decrease. The average anesthesiologist devotes slightly more than half of his time (i.e. roughly 30 hours) to anesthesia in the operating room (OR); another important area of activity is intensive care, on average slightly over 8 hours per week or 15 percent of his overall time. About 90 percent of the anesthesiologists are involved in anesthesia in the OR and in continuing medical education, nearly half have educational duties and 20 percent undertake research. Based on financial considerations, 18 percent of the respondents believe there are too many anesthesiologists. In contrast, only 6 percent think this is the case when considering the quality of anesthesia only, and no less than 39 percent believe that there are too few anesthesiologists. According to nearly half of the respondents, the anesthesia workload is somehow too heavy; nevertheless, only 18 percent would be prepared to work less if this would mean a loss of income, and 25 percent is not willing at all to work less, irrespective of income loss. Over three quarters of respondents indicate a job satisfaction of 7 on a scale ranging from 0 to 10; this mark might be further increased by a higher salary and by an improved image of their profession. Pain management is the area of anesthesiology that needs to be developed first. The respondents considered professional insurance, medico-legal problems, and an excess of anesthesiologists, as main sensitive points for the future development of this specialty.

Can we predict the future evolution of anesthesiology workforce in Belgium?

Two models are proposed to predict the evolution of anesthesiology workforce over the next 20 years. Each model features various scenarios according to different assumptions related to future numbers of female anesthetists, working hours, or regulations for postgraduates' working for conditions. However the main uncertainties derive from the unknown evolution of demands. Despite their differences both models agree on several important conclusions: a 13 to 14% shortage of anesthesiologists currently exists to satisfy O.R. demands, this shortage will decrease over the next ten years, and after 2010 a new shortage could arise under the combined pressure of the numerus clausus, of the number of female anesthesiologists and of the aging of the still young population of anesthesiologists.

[Future potential of the young surgeon]. / De toekomstmogelijkheden van de jonge chirurg.

An inquiry, held at the General Surgery Unit of the University Hospital in Leuven in the beginning of 1986, showed that none of the 64 assistant-surgeons, trained between 1976 and 1985, is unemployed at the moment. The majority of these young surgeons is satisfied with their present situation. For many however, it appears to be difficult to chose a direction in which they can be operative afterwards. A solution to this problem could be found in the organisation of the medical staff, comprising 2, 3 or 4 general surgeons who could take turns for the routine jobs and still enlarge each of them a certain ability in one or other subspecialization.