Surgical technology and operating-room safety failures: a systematic review of quantitative studies.

BACKGROUND: Surgical technology has led to significant improvements in patient outcomes. However, failures in equipment and technology are implicated in surgical errors and adverse events. We aim to determine the proportion and characteristics of equipment-related error in the operating room (OR) to further improve quality of care. METHODS: A systematic review of the published literature yielded 19 362 search results relating to errors and adverse events occurring in the OR, from which 124 quantitative error studies were selected for full-text review and 28 were finally selected. RESULTS: Median total errors per procedure in independently-observed prospective studies were 15.5, interquartile range (IQR) 2.0-17.8. Failures of equipment/technology accounted for a median 23.5% (IQR 15.0%-34.1%) of total error. The median number of equipment problems per procedure was 0.9 (IQR 0.3-3.6). From eight studies, subdivision of equipment failures was possible into: equipment availability (37.3%), configuration and settings (43.4%) and direct malfunctioning (33.5%). Observed error rates varied widely with study design and with type of operation: those with a greater burden of technology/equipment tended to show higher equipment-related error rates. Checklists (or similar interventions) reduced equipment error by mean 48.6% (and 60.7% in three studies using specific equipment checklists). CONCLUSIONS: Equipment-related failures form a substantial proportion of all error occurring in the OR. Those procedures that rely more heavily on technology may bear a higher proportion of equipment-related error. There is clear benefit in the use of preoperative checklist-based systems. We propose the adoption of an equipment check, which may be incorporated into the current WHO checklist.

Role of virtual reality simulation in teaching and assessing technical skills in endovascular intervention.

Training in endovascular intervention ultimately aims to produce interventionalists who demonstrate competence in technical skills. Herein, the authors investigate the rationale for simulation-based training by providing an overview of the psychological theories underpinning acquisition of technical skills, training and assessment history, recent advances in simulation technology, and a critical appraisal of their role in training and assessment in endovascular intervention. Simulators have potential for training and assessment and promise solution to many shortcomings of traditional 'apprenticeship' training models. Before inclusion into the curriculum, further work is needed regarding fidelity, validity, reliability, and design of simulators to ensure accurate transfer of acquired endovascular skills from simulator to patient.

Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization.

OBJECTIVE: We review our ongoing experience with a transabdominal stent repair of complex thoracoabdominal aneurysms (Crawford type I, II, and III) with surgical revascularization of visceral and renal arteries. METHODS: A retrospective review was conducted of prospectively collected data from 29 consecutive patients who underwent an attempted visceral hybrid procedure between January 2002 and April 2005. Twenty-two patients were elective, four were urgent (symptomatic), and three were emergent (true rupture). The median patient age was 74 years (range, 37 to 81 years). The aneurysms were Crawford type I in 3, type II in 18, type III in 7, and type IV in 1. Previous aortic surgery had been performed in 13 (45%) of 29 and included aortic valve and root replacement in 3, TAA repair in 1, type I repair in 1), type IV repair in 3, type B dissection in 2, infrarenal aneurysm in 5, and right common iliac aneurysm in 1. Severe preoperative comorbidity was present in 23 (80%) of 29: chronic renal impairment in 5, severe chronic obstructive pulmonary disease in 6, myocardial disease in 11 at New York Heart Association grade II (6) and grade III (5), and Marfan's syndrome in 6. Twenty-six patients (90%) had a completed procedure. In two patients, myocardial instability prevented completion of the procedure despite extensive preoperative cardiac assessment, and in one, poor flow in the true lumen of a chronic type B dissection prevented anastomosis of the revascularization grafts. Exclusion of the full thoracoabdominal aorta was achieved in all 26 completed procedures and extended to include the iliac arteries in four, with revascularization of coeliac in 26, superior mesenteric artery in 26, left renal artery in 21, and right renal artery in 21). RESULTS: There was no paraplegia < or =30 days or during inpatient admission, and elective and urgent mortality was 13% (3/23). All of the patients with ruptured thoracoabdominal aneurysms died < or =30 days. Major complications included prolonged respiratory support (>5 days) in 9, inotropic support in 4, renal impairment requiring temporary support in 2 and not requiring support in 2, prolonged ileus in 2, resolved left hemispheric stroke in 1, and resection of an ischemic left colon in 1. Median blood loss was 3.9 liters (range, 1.2 to 13 liters). The median ischemia time was 15 minutes (range, 13 to 27 minutes) for the superior mesenteric and coeliac arteries and 15 minutes for the renal arteries (range, 13 to 21 minutes). The median hospital stay was 27 days (range, 16 to 84 days). Follow-up was a median of 8 months (range, 2 to 31 months), with 92 of 94 grafts patent. Six patients were found to have a type I endoleak. In four, this was a proximal leak, and stent extension in three reduced, but did not cure, the endoleak. One patient with a distal type I endoleak was successfully treated by embolization. Four type II endoleaks resolved without intervention, and one was treated by occlusion coiling of the origin of the left subclavian artery. A single late type III endoleak was found. CONCLUSION: Early results of visceral hybrid stent-grafts for types I, II, and III thoracoabdominal aneurysms are encouraging, with no paraplegia in this particularly high-risk group of patients. These results have encouraged us to perform the new procedure, in preference to open surgery, in Crawford type I, II, and III thoracoabdominal aortic aneurysms.

Spontaneous resolution of a portal vein stenosis over a 21-month period in a "split-liver" transplant: demonstration by colour Doppler ultrasound, catheter angiography and splenic pulp pressures.

Portal vein stenosis in a "split-liver" transplant patient is demonstrated on colour Doppler ultrasound and indirect portography with raised splenic pulp pressures which resolves over a 21-month period without surgical or radiological intervention. When a portal vein stenosis in a liver transplant is encountered without severe derangement of liver function tests or signs of portal hypertension, regular follow-up colour Doppler ultrasound surveillance allows for evidence of spontaneous resolution.