Surgical mistakes and surgical quality.

Recently, surgical mistakes have been highlighted in the Belgian press because of surgical instruments left behind in the abdomen of patients. Fortunately this occurs very rarely.

However, it has been said that more people die every year because of surgical mistakes than by car accidents Google ‘surgical mistakes’ and the problem and the stakeholders become clear. This however is only the tip of the iceberg. The most frequent problem indeed in surgery is patients providing “informed consent” based upon incomplete information and lack of information concerning surgical quality (ie. the surgeon’s experience and complication rates). For most patients it is not very clear which quality of surgical care will be given, and this care varies from the best available to the minimum practice, which is the medico legal standard. This can be highlighted by the observation that it takes between 10 and 20 years or longer before innovation is introduced; the slow introduction of laparoscopic surgery is an example of this – it is only today, 30 years after its introduction, that laparoscopy is more or less accepted as the standard of care when performing a hysterectomy, removing fibroids, and treating endometriosis
This website principal aim therefore is providing information for the patient which is considered essential for obtaining informed consent .

Surgical quality often is suboptimal

There is no official/formal quality control for individual surgical intervention . National statistics only reveal complications. But without evidence of the entire surgical procedure it is very hard to demonstrate the underlying mistake, which may have caused the complication. For this reason we published in 2009 the recommendation that systematic videoregistration of complete interventions should be mandatory. Although this would permit evaluation afterwards, videoregistration is strongly opposed for various reasons; medico legal considerations being one of them. One aspect, however should be crystal clear, that the price cannot be a problem since the cost of a DVD (sufficient for an entire operation) is less than 1 euro. As an example, to highlight the advantages of videorecording our article concerning ureter surgery, demonstrated that without videorecording it is impossible to distinguish between mistakes, accidents and complete surgery necessitating an ureter lesions eg. when treating infiltrating endometriosis.
Suboptimal surgical quality has many faces:

Surgery can last much longer than necessary .Besides the consequence of being under anaesthesia for longer than necessary and that the costs for society are higher, most importantly, postoperative adhesions will increase leading to infertility, pain and possible reoperation
Inadequate experience of the surgeon.It is suggested that the patient should be informed about the results and experience of the surgeon. For example, the patient should be told if the surgeon is still in his/her learning curve or when the surgeon is performing an intervention for the first time . This obviously can be circumvented to some extend by the presence of an experienced surgeon during the training of registrars. The patient should be informed who that experienced surgeon is – and how experienced he/she is. Laparoscopic surgery, increases this problem, since guidance is more difficult and consequently the duration of the surgery can increase exponentially
Unnecessary bleedings, which also will increase postoperative adhesions
Incomplete surgery leading to reinterventions. Especially for deep endometriosis surgery this is a major problem .
Unnecessary bowel resections , which often are performed by some groups almost systematically for deep endometriosis without any proven benefit in comparison with a more conservative discoid resection, as highlighted in a recent systematic review on bowel resections for deep endometriosis and as shown in the recent PhD of Dr Jean Squifflet (promoter Professor Jacques Donnez) at the UCL (Universite Catholique de Louvain, Belgium). When no endometriosis is found as occurs in 14% is becomes worse.
Avoidable damage or unnecessary removal of ovaries. This problem becomes obvious when it is realised that the prospective reports of surgical groups do not demonstrate a decrease of ovarian reserve after surgery, whereas the IVF groups publish an important decrease in ovarian reserve after previous ovarian surgery . This also was the key topic I spoke to when receiving the ASRM distinguished surgeon award-in Philadelphia in 2004, suggesting that those performing IVF might have a conflict of interest concerning surgery for which most only have a basic training.
A laparotomy for an intervention that can be performed by laparoscopy and this notwithstanding the advantages of MIS The magnitude of this problem results clearly from the observation that many of the pioneers in endoscopic surgery since 1996 only performed total laparoscopic hysterectomies or vaginal hysterectomies. This is in sharp contrast with the fact that in 2010 many hysterectomies are still performed by laparotomy in Belgium and in the USA. This highlights that information prior to the surgery must have been inadequate since otherwise women would not still choose to have a laparotomy. The same holds true for most of the gynaecologic interventions, including oncology where laparotomy is still widely used. We therefore suggest that pelvic surgery, as a specific subspecialty in gynaecology, would be preferable to promoting gynaecologic oncology as a specific subspecialty.

2010_the-elephant.pdf

The indication for surgery was wrong

When the indication for surgery is erroneous, things get worse. This becomes apparent when we consider the life time risk of undergoing an hysterectomy, which varies from 50% (USA) over 35% (Belgium) to 25%(UK) and 17%(Sweden) . Moreover many hysterectomies could be prevented by hysteroscopic surgery or by medical therapy. Also in pelvic floor surgery we should realise that not that many surgeons can perform all techniques varying form vaginal (mesh) surgery, to promontofixation, paravaginal defect and the laparoscopic Burch, fur urinary incontinence.

Surgery was not necessary or could have been avoided.

This happens not only for hysterectomies, or for the removal of ovaries (instead of a cystectomy), also after a bowel resection for endometriosis, where endometriosis is not always even confirmed.

Informed consent without adequate information

Information is rarely complete to the extent that the patient can judge all treatment options, nor the experience and results of a surgeon. Regretfully it is not standard practice that a patient is told the advantages of a laparoscopic intervention by a gynaecologist who does not himself/herself perform laparoscopic surgery.

Professor PR Koninckx

PS As related reading I recommend the very complete Endometriosis.org discussion on centers of excellence , my previous article on centers of excellence and my blog on politics in endometriosis surgery