Minimally invasive surgery prevails but is it as safe as you think it is?
Congressman's death makes providers re-examine procedures
Sometimes in the rush to adopt new surgical approaches that allows less scarring and quicker discharge, an important fact becomes lost: Minimally invasive procedures are serious surgery with inherent risks and potentially deadly postoperative complications. This lesson was brought to the forefront recently with the death of U.S. Rep. John Murtha (D-PA). He reportedly died after undergoing laparoscopic cholecystectomy and developing an infection.1
Laparoscopy has its limitations, emphasizes Michael S. Kavic, MD, director of education and general surgery at St. Elizabeth Health Center, Youngstown, OH, and associate dean for clinical education, professor of surgery, and vice chair in the Department of Surgery, Northeastern Ohio Universities College of Medicine, Rootstown, OH. Laparoscopy converts three-dimensional reality to a two-dimensional screen, he points out.
"We're taking blood and guts and converting it to bits and bites," he says. "That's a bit of a disadvantage."
In lap chole, the surgeon could be exerting force on an organ outside the field of view and be unaware of any damage, Kavic says. The risks are multiplied if the patient has had several previous surgeries and there are adhesions around the target organ, he says. One problem that is of particular concern to outpatient surgery providers is that complications might not manifest themselves until one to seven days after surgery, Kavic says.
"The patients can go home feeling halfway decent, and a few days later, they get symptoms chills and abdominal pain, which are signs of systemic infection," he says.
There are steps that outpatient surgery programs can take to minimize the risks during minimally invasive surgery, according to Kavic and other experts. They include:
Thorough informed consent.
Laparoscopic surgery is usually safe, "but unfortunately it's not 100% safe 100% of the time," Kavic says. Patients must be informed of the risks, the alternatives and their risks, and what should be a reasonable expectation, he adds. Patients must understand this information, Kavic says. Additionally, it's important for patients to inform physicians thoroughly about their medical history, including any previous surgeries, he says.
The issue of previous surgeries is an important one, particularly because many procedures that formerly were performed inpatient are moving to the outpatient arena, says Stephen Trosty, JD, MHA, CPHRM, ARM, president of Healthcare Risk Consultants in Haslett, MI. Patients should be questioned as to whether they had any problem in recovery or whether they developed complications after previous surgeries, he says.
"I think they need to know does the person have any allergies with anesthesia or ever had any problems with anesthesia in the past," he says. "Does the person have any heart-related issue or problems that should be known about and taken into consideration?"
Thorough patient education.
Patients must understand that even with minimally invasive procedures, injuries can occur, Kavic says. "Video game-like surgery doesn't mean it doesn't have risks and complications associated with it," he says. "Patients have to know that."
The discharge instructions should include symptoms of common complications and what patients should do if they experience those symptoms, says Waldene K. Drake, RN, MBA, vice president of risk management and patient safety for Cooperative of American Physicians in Los Angeles. "Also on that education sheet, the patient needs to be given a 24-hour number to call or told what symptoms require that they go to an ED," she says.
Patients must be alerted to notify providers if they experience pain associated with any other symptoms such as fever, nausea and vomiting, racing heart rate, and/or shortness of breath, Kavic says.
Convince patients and their families you want to hear from them if anything's not perfect, says Steven D. Schwaitzberg, MD, chief of surgery at Cambridge (MA) Health Alliance and associate professor of surgery at Harvard Medical School, Boston. Schwaitzberg also is the incoming president-elect of The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). "Patients, when you talk to them, might not remember a list, or they may lose a piece of paper, but if they know the doctor wants them to call if anything is wrong, that's perhaps the single most important thing they can remember," Schwaitzberg says.
Use your discharge criteria.
When performing a retrospective examination of surgical complications that show up after discharge, consider whether the patients were sent home appropriately after meeting discharge criteria, Schwaitzberg says.
It's important to not only have a discharge system with criteria, but to use the system, he emphasizes. "Discharge criteria were developed to catch people who are demonstrating objective signs of early complications," Schwaitzberg points out.
Pay attention to post-op checklist
Staff members must pay attention to every line on their postoperative checklist, Drake emphasizes. "These are the standard of care for postoperative nursing care, and if abnormalities are charted but not acted upon, the care is hard to defend, and a complication may not be recognized early enough," she says.
Also pay attention to the patient's complaints, Drake says. "For example, pain can be brushed aside as incisional pain when it may be an early warning of injury to an internal organ or numbness due to nerve injury may be brushed away as a residual to the cuff which was in place during surgery," she says.
Physicians must examine any patient with post-op problems.
Whoever is taking calls from patients postoperatively, whether they are office managers or nurses, needs to err on the side of patients being examined rather than assume a problem is inconsequential, says L. Michael (Mike) Brunt, MD, professor of surgery at Washington University at St. Louis.
Patients who have a significant problem other than pain, such as nausea and vomiting, unable to tolerate anything by the mouth, gas, or fever, and patients who have generalized pain through the abdomen, should be treated differently from patients who simply have pain at the incision site, Brunt says. "The challenge is to differentiate significant issues from those that can be handled over the phone," he says.
Schwaitzberg concurs and says physicians should have a low threshold for examining those patients who call, Schwaitzberg says. "The answer is always the same: Come in, and study them," he says. "Most exams will result in nothing more than reassurance, but the one time you find something, it may be life-saving."
This willingness to examine patients is particularly important in the first week or so after surgery, Schwaitzberg says. Whether the exam is done in the emergency department or the physician's office, "it's important for someone to put their eyes on the patient and make sure there is not an acute surgical problem," he says.
At your staff meetings, include case studies about procedures that "went wrong," including early warning signs that were missed and the outcome, Drake advises. "Everyone learns from real life cases," she says.
Minimally invasive procedures have become commonplace, Schwaitzberg says, and "familiarity breeds contempt."
"Just because I've done a 1,000 in a row doesn't mean the next one can't be injured," he says. "Vigilance should be part of the DNA of everybody who does invasive procedures."
- Neergaard L. Lawmaker's death a reminder of surgery risks. Feb. 9, 2010.