Surgical safety update

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In a joint safety initiative, Getting It Right First Time (GIRFT), NHS England and the Royal College of Surgeons of England have produced best practice guidance for documentation of the following procedures: inguinal hernia repair, laparoscopic appendicectomy, laparoscopic cholecystectomy, laparotomy and laparoscopic bowel resection, and thyroidectomy.

The following four cases are vignettes, provided by GIRFT, and have been discussed by the CORESS Advisory Board. The events in these cases underpin the need for comprehensive and thorough documentation for these procedures.

Injury from insertion of a laparoscopic port

The patient had a complex surgical history, with multiple abdominal procedures including hysterectomy, fundoplication for reflux, cholecystectomy and incisional hernia repair. The patient developed an inguinal hernia and was admitted to hospital for laparoscopic repair.

After the port was inserted into the patient’s abdomen their blood pressure dropped, the procedure was converted to laparotomy, a perforation of the left common iliac artery was identified and the artery was clamped. However, the patient suffered a hypoxic brain injury as a result of the bleeding from the artery, leaving them with significant disability, including mobility and cognitive problems.

An operation note was not completed by the surgeon (because the complication arose after insertion of the port and therefore the surgery never really got underway) and, in the absence of any alternative contemporaneous explanation, it had to be accepted that the arterial damage was probably caused by the surgeon inserting the port too far into the abdomen. Early admission of liability was made on that basis and substantial damages exceeding £3m were paid to the claimant. Legal costs were in the region of £500,000.

GIRFT message:

A detailed operative note is required, regardless of when in the procedure a complication occurs. When inserting laparoscopic ports, key details including anatomical location, technique used (including whether under direct vision), and the pressure set should be recorded. It is also advised to record any intraoperative complications, including the findings and what actionwas taken to remedy them, noting conversion from a laparoscopic procedure to laparotomy, and recording any additional procedures performed together with the rationale for them.

CORESS comments:

A comprehensive operation note forms a fundamental component of communication in the continuity of surgical care beyond the operating theatre to all stations on the subsequent patient pathway. The Royal College of Surgeons of England has set out in detail the components of a good operation note in the document Good Surgical Practice¹. Further relevant details are provided in Hoggett L, How to write an operation note². The CORESS Advisory Board noted that it was particularly important to document untoward, unusual or adverse occurrences in the event that documentation is subsequently relied on for medicolegal purposes. Where feasible, a drawing or illustration may significantly enhance a reader’s understanding of the procedure undertaken.

Incomplete removal of appendix

A patient underwent a laparoscopic appendicectomy, which was uncomplicated. He returned 18 months postoperatively with further right-sided pain. Having been investigated for over one year he was admitted for laparoscopic stump appendicectomy. At surgery the patient was found to have an appendix approximately 12.5cm in length. This was explained as duplicate appendicitis, but there was no evidence for this. The likely explanation was incomplete appendicectomy, but surgical records were scant.

A clinical negligence case was brought and admissions had to be made in the absence of a clear documentation to the contrary.

GIRFT message:

Documenting operative findings, including any stump level left and operative technique, with detailed and clear description is important, not just in potentially defending a later claim, but more importantly in managing ongoing patient care if postoperative difficulties are suffered.

CORESS comments:

CORESS noted that there appeared to be no match of pathological records to the procedure. It was also discussed that keeping a pictorial record at the time of laparoscopic appendicectomy might have facilitated a defence in this case. Finding the appendix may be difficult at appendicectomy. Mobilisation of the caecum allows identification of the taeniae coli, the three separate bands of smooth muscle that converge on the vermiform appendix and may aid identification of this structure.

Alleged nerve injury during laryngectomy   

A patient underwent laryngectomy and left hemi-thyroidectomy due to a laryngeal tumour. While the operation was a success, the patient unfortunately suffered injury to the hypoglossal nerve, which affected their speech and ability to swallow. Detailed operative records showed no evidence of negligence and the claim, subsequently brought for clinical negligence, was successfully defended at trial.

GIRFT message:

Sometimes events occur that are not expected, are rare and cannot necessarily be explained. Depending upon the circumstances of the case, wholly unexpected events are not negligent. While this case was rightly defended with the benefit of impressive witness evidence, this would have not been possible without the detailed operative note that clearly identified key structures that had been appropriately protected. The opportunity was still taken among clinical staff to reflect on what might be done in future to avoid any adverse outcomes by ensuring all documentation has sufficient detail to defend such a claim.

CORESS comments:

CORESS agreed that some adverse incidents are recognised complications of surgical procedures. In addition to keeping scrupulous operative records that record identification and protection of structures at risk, comprehensive preoperative consent covering all potentially likely complications should be undertaken.

Failure to interpret an operative cholangiogram correctly

A patient was admitted for a laparoscopic cholecystectomy. A large stone had been identified in the gallbladder and this proved difficult to retract. Calot’s triangle was fully dissected and the presumed cystic duct was tied distally. An on-table cholangiogram was undertaken. The operative cholangiogram was interpreted wrongly leading to excision of the bile duct, with transection in its distal portion and proximally in the hilum of the liver. The above was not recognised during the operation and the patient was subsequently discharged. All appeared to have gone well. The patient then suffered severe pain and was readmitted with sepsis. The patient had to undergo further, and this time urgent, surgery where the previous error was recognised and addressed. Admission to intensive care was then required.

Unfortunately the negligent interpretation of the cholangiogram, and therefore inaccurate documentation of the intraoperative findings, did lead to significant difficulties for this patient. While not appreciated at the time, it did not take long for clinicians to reflect and for an early admission of substandard care to follow. Liability was admitted at an early stage and the clinical negligence claim was swiftly resolved. An apology from the Trust’s Chief Executive was provided.

GIRFT message:

Recognition of an error by the surgeon who was prepared to go on record to diagnose the complication and admit liability allowed the patient to receive the right treatment for the complication and for the claim to be resolved swiftly, reducing the risk of additional costs for failure to follow up.

CORESS comments:

If a cholangiogram is requested, it should be interpreted correctly. It was noted that this could have been a case of confirmation bias, in which, if new information is provided that does not fit with an established preconception, then the latter information may be disregarded. It was also noted that bile duct injuries of this nature should be dealt with by specialist centres and not by the surgeon who has caused the primary injury.

Harriet Corbett
Programme Director on behalf of the CORESS Advisory Board