Untangling surgical snags

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Surgery comes with a collection of scary possibilities, from anesthetic crises to runaway bleeds to introduced infection. But the patient is not the only one who suffers from these hitches: It is also the surgeon who bears scars.

“I read the (social media) posts of veterinarians who are really suffering from the anxiety and stress of surgical complications, and the psychological impact is interesting,” said Philipp Mayhew, BVMS, DACVS, professor of soft tissue and minimally invasive surgery at the University of California, Davis School of Veterinary Medicine during his lecture "Surgical Complications: Risk, Mitigation & How to Cope When They Occur," at the 2023 Western Veterinary Conference in Las Vegas, Nevada.

Surgery, he warned, is not for everyone, and it is up to each doctor to know thyself. “There are a lot of things that you can do that don’t involve surgery. You should pursue these if the stress of surgery is too much.”

Group the gaffes

Globally, human medicine logs some 400,000 deaths due to medical complications every year,¹ many related to surgery. Nearly 1 in 10 hospitalized patients suffers adverse events, most connected to surgery, and over 7% are fatal.²

“These are horrendous numbers,” said Mayhew, “so we’re not alone in veterinary medicine.”

By classifying surgical complications, he explained, we can compare “apples to apples” over time, and across institutions and medical procedures. Summed up, these objective metrics enable us to see how we’re doing in the OR.

On the human side, many arbitrary attempts have been made over the years to classify post-op problems. The first to standardize these negative outcomes was the Clavien-Dindo Classification,³ which grades any deviation from the normal postoperative course into categories based on extent of intervention needed and severity of sequelae. These can range from minor pharmacological treatment to ICU management, mild dehiscence to death.

The subsequent Accordion Severity Grading System changed up the clusters to clarify level of gravity.⁴ Likewise, similar classification systems have been drawn up for the veterinary world.

Elements of jeopardy

The chief variables impacting any surgical outcome are patient status, operative approach, hospital factors and surgeon experience with that specific procedure.

In people, a patient who is frail, elderly, and/or who has underlying health problems or elevated anesthetic risk score is a weaker candidate for surgery, he explained. But procedure matters, and those that are minimally invasive present fewer complications and lower mortality rates than do major surgeries, regardless of patient status.

As far as the hospitals themselves go, Mayhew added, lower mortality is connected to higher nurse: patient ratio, technological sophistication, large hospital size, and status as a teaching hospital.

The last variable, surgeon capability, adheres to the infamous 10,000-hour rule that holds that anyone can become an expert in any endeavor with enough repetition. The human surgeon generally focuses on a few different procedures that he or she performs over and over. For their handful of trademark surgeries, they achieve low complication rates.

At a small Toronto hospital - known as the “hernia factory” for its sole offering, inguinal hernia repair - surgeons each perform 600-800 of the procedures. Despite not having completed general surgery training, they excel at sealing abdominal blips because they stick to one thing. Their hernia recurrence rates are a mere 1%, brag-worthy next to the average 10-15% breakdown frequency for general surgeons.^5,6

It’s strong evidence, said Mayhew, that “you don’t need to be a top surgeon. You just need repetition.”

Except for spays and neuters, repetition of specific surgeries is less available for veterinarians. "We don’t get to do 200 of something in a year,” he explained. “Veterinary medicine will never get to the levels of low morbidity that they have in human medicine because we just don’t have the repetition.”

Whether the patient is human or animal, the benefits of surgical iteration may tail off over time. A study looking at surgeon experience in relation to occurrence of complications in human thyroid surgery found that surgeons over 35 years old were less likely than younger doctors to damage surrounding structures like the parathyroid glands and the recurrent laryngeal nerve.⁷ But after the age of 50, their experience was overshadowed by the limits of aging.

Cut the risk

The first and foremost step in averting surgical mishaps is selecting cases appropriately, based on one’s strengths and limitations. Some surgeons excel at orthopedic surgeries but struggle with soft tissue procedures, and vice versa. Likewise, Mayhew continued, “If it’s a complex procedure, send it to the most qualified person for it.”

To do this, he reminded, one must get over what he referred to as the pride thing. In a nod to all that can go wrong when a dog or cat is laid out on the operating table, one must have a Plan B and even a Plan C before making that first notch. Having special vessel-sealing devices on hand that melt vascular collagen and elastin provides an added measure of safety.

Also, use checklists. Multiple veterinary studies show that surgery checklists cut anesthesia duration and reduce post-op wound complications.^8,9 A comprehensive checklist should incorporate good habits to be repeated every time, and in the same order. This should include things like reviewing imaging before every case, ensuring equipment and devices are working and enough surgical assistance is available, placing catheters in orifices and suture loops around vital structures, and, before closure, counting sponges and inspecting for hemostasis.

Incision size must be adequate to enable good visualization, Mayhew said, and surgeons should take time to plot out surrounding anatomy. Both measures help avert mistakes, such as the accidental prostatectomies that sometimes happen during cryptorchid castrations, and inadvertent clamping of ureters. perhaps in the rush to stop a bleed.

How one handles crisis OR moments, which every surgeon encounters at some point, often determines outcome. Unfortunately, the go-to emotion here is panic. And panic, he said, is a pointless emotion because you tend to do rash things when you are panicking.

Trigger-finger slicing and nervous ligation can permanently destroy function, changing an animal’s life forever. So if one encounters a snag, Mayhew stressed, he or she should know when to ask for help… and when to stop and retreat: “Suture the belly up and send it to someone else.”

Breaking bad news to pet parents

Suppose surgery doesn’t go as planned! There are several ways to deliver unsettling tidings¹⁰:

• Be blunt (“Mrs. Smith, your dog is dead.”)
• Stall (Bury the news in technical details.)
• Forecast (In this, the recommended approach, the message is staged by first indicating the news is bad and then following with pertinent information.)

When potential complications are discussed with the pet owner prior to surgery, the bad news generally lands easier when things go wrong.¹⁰ It’s key to document these presurgical talks, which should also include a review of patient-specific risks, such as hypoxic damage for the brachycephalic dog or post-op infection for the diabetic patient.

Have a plan ready to roll in case problems develop post-operatively and convey this plus your assurance to stay the course with the pet until the situation is resolved. Remember that owners are generally forgiving of surgical complications, even slip-ups. A study of dogs undergoing TPLO for treatment of cranial cruciate ligament injury revealed that setbacks developed in approximately 25% of cases, but that the occurrence of complications did not affect owner assessments of outcome.¹¹

Lastly, Mayhew advised, be sure to apologize for surgical snafus, even those that are not your fault. Empathy is magnanimous and generates good feelings.¹² What drives lawsuits are poor communication and lack of transparency drives: A University of Michigan study showed that an open disclosure model slashed lawsuits significantly.¹³

Coping tools for remaining resilient

In human medicine, morbidity and mortality rounds are a vital element of quality improvement, patient safety, and risk management. Generally led by residents and legally confidential, these collective probes enable doctors to learn from mistakes, miscalculations, and the realities of Mother Nature. These “what would we do differently?” meetups, Mayhew noted, are generally considered the most enlightening elements of medical residency.

Surgeons commonly feel guilt, anger, embarrassment, anxiety, and post-traumatic stress in response to their clinical mishaps,¹⁴ but Mayhew offered a few pointers for implanting some zen while elevating surgical skill:

• Read the literature and learn from the mistakes of others.
• Attend conferences and use medical social media.
• Find time to practice outside of the operating room.
• Abstain from doing surgical procedures that cause you stress.
• Reflect on your errors.
• Forgive yourself.

References

1. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122-128. doi:10.1097/PTS.0b013e3182948a69
2. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139. Published 2016 May 3. doi:10.1136/bmj.i2139
3. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205-213. doi:10.1097/01.sla.0000133083.54934.ae
4. Strasberg SM, Linehan DC, Hawkins WG. The accordion severity grading system of surgical complications. Ann Surg. 2009;250(2):177-186. doi:10.1097/SLA.0b013e3181afde41
5. Malik A, Bell CM, Stukel TA, Urbach DR. Recurrence of inguinal hernias repaired in a large hernia surgical specialty hospital and general hospitals in Ontario, Canada. Can J Surg. 2016;59(1):19-25. doi:10.1503/cjs.003915
6. Neumayer LA, Gawande AA, Wang J, et al. Proficiency of surgeons in inguinal hernia repair: effect of experience and age. Ann Surg. 2005;242(3):344-352. doi:10.1097/01.sla.0000179644.02187.ea
7. Bergström A, Dimopoulou M, Eldh M. Reduction of Surgical Complications in Dogs and Cats by the Use of a Surgical Safety Checklist. Vet Surg. 2016;45(5):571-576. doi:10.1111/vsu.12482
8. Duclos A, Peix JL, Colin C, et al. Influence of experience on performance of individual surgeons in thyroid surgery: prospective cross sectional multicentre study. BMJ. 2012;344:d8041. Published 2012 Jan 10. doi:10.1136/bmj.d8041
9. Cray MT, Selmic LE, McConnell BM, et al. Effect of implementation of a surgical safety checklist on perioperative and postoperative complications at an academic institution in North America. Vet Surg. 2018;47(8):1052-1065. doi:10.1111/vsu.12964
10. Thieman Mankin KM, Jeffery ND, Kerwin SC. The impact of a surgical checklist on surgical outcomes in an academic institution. Vet Surg. 2021;50(4):848-857. doi:10.1111/vsu.13629
11. Shaw J, Dunn S, Heinrich P. Managing the delivery of bad news: an in-depth analysis of doctors' delivery style. Patient Educ Couns. 2012;87(2):186-192. doi:10.1016/j.pec.2011.08.005
12. Priddy NH 2nd, Tomlinson JL, Dodam JR, Hornbostel JE. Complications with and owner assessment of the outcome of tibial plateau leveling osteotomy for treatment of cranial cruciate ligament rupture in dogs: 193 cases (1997-2001). J Am Vet Med Assoc. 2003;222(12):1726-1732. doi:10.2460/javma.2003.222.1726
13. Birks Y, Harrison R, Bosanquet K, et al. An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review and qualitative exploration. Southampton (UK): NIHR Journals Library; July 2014.
14. Boothman RC, Imhoff SJ, Campbell DA Jr. Nurturing a culture of patient safety and achieving lower malpractice risk through disclosure: lessons learned and future directions. Front Health Serv Manage. 2012;28(3):13-28.