Errore e qualità in chirurgia ginecologica
Surgical mistakes and surgical quality
Recently, surgical mistakes have been highlighted in the Belgian press because of some “forgotten ” surgical instruments in the abdomen of patients. Fortunately this occurs very rarely. 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 informed consent based upon incomplete information and lack of information concerning surgical quality. For most patients it is not very clear which quality of surgical care will be given this varies from the best available to the current practice, which is the medio 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. This website principal aim therefore is information of the patient.
Surgical quality often is suboptimal
There is no quality control for the individual surgical intervention . National statistics only reveal complications, while it is very hard to demonstrate the eventually underlying mistake. For this reason we published a few years ago 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,and that is the the price which 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 recent article concerning ureter surgery, we demonstrated that without videorecording is is impossible to distinguish between mistakes, accidents and complete surgery necessitating an ureter lesions eg when infiltrating endometriosis.
Suboptimal surgical quality has many faces.
Surgery can last much longer than necessary . Besides the consequence That anaesthesia takes longer than necessary and that the costs for society are higher, most importantly, postoperative adhesions will increase leading to infertility, pain and reoperation
Inadequate experience of the surgeon. It was suggested that the patient should be informed about the results and experience of the surgeon, ie when the surgeon is still inhis 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 training of registrars. Laparoscopic surgery, increased this problem, since guidance is more difficult while duration of 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 , zoals which often are performed almost systematically for deep endometriosis without any proven benefit in comparison with a more conservative discoid resection, as highlighted z in a recent systematic review on bowel resections for deep endometriosis and as shown in the recent PhD of Dr Jean Squifflet ( promoter Prof Donnez) at the UCL.
Avoidable damage or unnecessary removal of ovaries. The scope of 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 2 years ago. This also was a key topic when receiving the ASRM distinguished surgeon award- in Philadelphia, sugegesting 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 nothwithstanding 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 observation that in 2010 many hystrectomies are still performed by laparotomy in Belgium and in the USA. This moreover highlights that information must have been inadequate 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 the pelvic surgeon, as a specific subspecialty in gynaecology, would be preferable instead of promoting gynaecologic oncology as a specific subspecialty.
The indication for surgery was wrong
When the indication for surgery was erroneous, things get worse. This becomes apparent when we consider the live time risk of undergoing an hysterectomy,which varies from Dit komt in gynaecologie 50% (USA) over 35% (Belgie) to 25%(UK) and 17%(Zweden) . Moreover many hystrectomies 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 promontofixatone, paravaginal defect en de laparoscopic Burch.
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, endometriosis is not always confirmed.
Informed consent without adequate information
Information is rarely complete to the extend that the patient can judge about alternative treatments, about the experience and results of a surgeon. It indeed is not standard practice that a patient is told the advantages of a laparoscopic intervention by a gynecologist who does not do laparoscopic surgery.
Prof PR Koninckx