Comparing Surgical Site Infection for Open and Endoscopic Component Separation.

In March 2016, we reported the SSI rate at LSU Health for all abdominal wall hernia repairs performed between 2011 and 2013. Among the 263 repairs, the infection rate averaged 6.8 per cent. Given the diversity of repairs, this global percentage lacks relevance, but looking at subsets provides meaningful insights. For example, SSI was 1.8 per cent among 55/263 laparoscopic repairs and 8.2 per cent among 206/263 open repairs. The infection rate of 26.3 per cent among the 19 open component separation cases was especially noteworthy and bothersome. Even though there was no mortality in any subset, the vast majority of the morbidity and costs involved repairs with open component separations. A meta-analysis published in 2016 revealed a likely SSI benefit for the endoscopic component separation technique (ECST) over the open CST. Since that report, we have focused our quality improvement efforts on this subset of challenging cases and have replaced CST with ECST. Our data now include results from 33 hernia repairs with either CST or ECST that were performed between November 2011 and April 2018. Twenty-four of 33 patients had CST with an SSI rate of 37.5 per cent (9 of 24). Nine of 33 had ECST with 0 per cent SSI (P value = 0.039). These results mirror the findings reported in the meta-analysis.

Repair of Large Sliding Inguinal Hernias.

Sliding inguinal hernias are often unexpected intra-operative findings, and repair of which can be technically challenging. A number of repair techniques have been described. The author modified a technique based on an approach described by Bevan. The purpose of our study is to describe this modified Bevan technique for repair of sliding inguinal hernias and report its efficacy in a series of patients. We retrospectively reviewed all patients with open inguinal hernia repairs performed by a single surgeon from August 2007 to April 2013 for sliding indirect hernias using the modified Bevan technique. Patient records were reviewed for demographics, hernia characteristics, complications, admission status, length of stay, and complications. There were 25 patients eligible for our review (male = 25, mean age = 49 years). All sliding hernias were indirect, none were bilateral, and two were incarcerated. The sliding component involved the bladder and perivesical fat (n = 12), sigmoid colon (n = 10), and the cecum and appendix (n = 3). Eighteen patients were treated as outpatients; seven patients were admitted with a mean stay of 2.2 days. Complications included intra-operative bleeding (n = 1), subcutaneous wound hematoma (n = 1), scrotal seroma (n = 1), transient orchialgia (n = 1), and ileus (n = 1). All patients were seen postoperatively for short-term follow-up with no hernia recurrences. Thirteen patients were available for long-term follow-up (mean = 13.6 months); all had no hernia recurrences. The modification of Bevan's technique for repair of large sliding hernias worked well in our series.

Reviews of liability claims against surgeons: what have they revealed?

Closed claims reviews are a robust source of severe surgical errors for study. Most errors are preventable. Most preventable technical errors and judgment errors occur during care provided by competent surgeons. Failure to operate within a proper scope-of-practice is the most common cause of incompetence. Patient factors and systems failures, including human factors, cause or profoundly contribute to the cause of most technical errors. Regardless of its cause or preventability, a technical error sets the stage for other errors in care that relate to systems' failures and surgeons' judgment failures. Failed judgment and poor decision-making are usually the result of cognitive errors caused by flawed behavioral practices instead of lack of knowledge. Systems of care and good behavioral practices are catalysts that maximize the power of knowledge and skill to achieve good outcomes. The uniform application of knowledge and skill in a favorable environment is as important as the possession of knowledge and skill. Identifying systems and behavioral causes of errors may help to define best practices and lead to safer patient care through improved systems of care and increased diligent attention to ordinary tasks that require more time than knowledge on the part of surgeons.

Violations of behavioral practices revealed in closed claims reviews.

OBJECTIVE: Closed claims against general surgeons were reviewed, seeking insights into the effects of surgeons' deficient behavioral practices on outcomes. Research and educational strategies based on findings may reduce errors and improve care. SUMMARY BACKGROUND DATA: Adverse events occur in 2.9% to 3.7% of hospital admissions in the United States. Of these adverse events, 27.4% to 32.6% are the result of errors. Failures at the point-of-service can undermine the other elements of systems of care designed to reduce preventable adverse outcomes. In this regard, the relative importance of surgeons' behavior is poorly defined. METHODS: Fellows of the American College of Surgeons (ACS) reviewed 460 malpractice claims against general surgeons. The relationship between detrimental behavioral practice patterns--deficiencies in care that reflected a lack of diligence, vigilance, and/or commitment of time more than a lack of knowledge and/or skill--and the preventability of adverse events was assessed. RESULTS: Failures in practice patterns of behavior occurred in 78% of cases and were frequently associated with preventable injuries. When both behavioral practice violations and technical misadventures occurred, the complications were more likely to be preventable than if only a technical misadventure had occurred. Among several deficient behavioral practices, the failure to communicate was most pervasive, accounting for 22% of complications in the study. CONCLUSIONS: Stakeholders in health care policy should focus on the issue of physician behavior in crafting shifts in institutional cultures and in targeting new CME toward evidenced-based behavioral practices.

The American College of Surgeons' closed claims study: new insights for improving care.

BACKGROUND: All physicians must be vigilant in the pursuit of safe care for patients. While problems in care are identified, education that provides an understanding of these problems and guidelines for improvement can enhance patient safety. Our objective was to determine problematic aspects of surgical care, including care provided by surgeons before, during, after, and instead of surgery, that negatively affect patient safety. STUDY DESIGN: Four hundred sixty malpractice claims against general surgeons were reviewed by surgeons (FACS). All claims were closed in 2003 or 2004. The data collection was completed at five medical liability companies representing a nationwide distribution of surgeons. Surgeons also dictated or wrote narratives for each case. The quantitative data and narratives were later analyzed to determine events responsible for unsafe care. RESULTS: Surgeon-reviewers identified deficiencies in care that fell below accepted standards more often before and after operations than during them. These deficiencies were often the result of a failure to recognize surgical injuries, and many of these deficiencies were preventable. The quality of surgical care was satisfactorily met in 36% of cases. The most common procedures involving patient safety concerns were those involving the biliary tract, intestines, hernias, vascular system, esophagus, and stomach. The most frequent events leading to claims included delayed diagnosis, failure to diagnose, failure to order diagnostic tests, technical misadventure, delayed treatment, and failure to treat. Complications occurring most frequently were organ injuries, adult respiratory distress syndrome, and infection. CONCLUSIONS: Closed claims reviews provide valuable data that may enhance provider performance through heightened awareness of common unsafe practices. Specifically, opportunities exist to improve surgical care provided during the preoperative and postoperative phases of treatment through continuing medical education to improve patient safety.

The sestamibi scan as a preoperative screening tool.

Sestamibi scan is generally recognized in the literature to play a role in the imaging of parathyroid adenoma. Most institutions quote sensitivities ranging from 80 to 100 per cent. There is still a question as to whether patients need preoperative localization studies. Preoperative localization can potentially result in less invasive surgery, shorter operative times, decreased hospital stays, and decreased need for re-exploration. Our hypothesis is that the sestamibi scan is a sensitive predictor of parathyroid adenomas. The objectives of this study are to determine the sensitivity of sestamibi scan in detecting parathyroid adenoma, and to determine whether either parathyroid hormone (PTH) level or calcium level is an independent predictor of a positive scan. One hundred patients were retrospectively reviewed at Louisiana State University Health Sciences Center-Shreveport and Louisiana State University Health Sciences Center-Monroe from March 1993 through December 2000. All patients had a preoperative sestamibi scan. This scan was performed using the dual-phase technique in which the parathyroid glands are visualized after washout of tracer from the thyroid. The scan was followed by either a unilateral or bilateral neck dissection. There were 82 female patients and 18 male patients who ranged in age from 23 to 78 years. The median weight of glands with a positive scan was 795 mg. The median weight of glands with a negative scan was 480 mg. This difference was statistically significant (P < 0.04). Overall there were 107 adenomas. Of these 93 had positive scans and 14 had negative scans. This results in a sensitivity of 87 per cent. There were 67 glands that weighed at least 500 mg. Of these 67 glands 61 had positive scans and six had negative scans. This resulted in a sensitivity of 91 per cent. There were 40 glands that weighed less than 500 mg. Of these 40 glands 32 had positive scans and eight had negative scans. This resulted in a sensitivity of 80 per cent. Using multiple linear regression analysis calcium level correlated with the weight of the gland (P < 0.01). Calcium level also correlated with the PTH level (P < 0.01). However, neither the PTH level nor the calcium level correlated with a positive sestamibi scan. Sestamibi scan is a sensitive predictor for parathyroid adenoma greater than 500 mg (91% sensitivity). Even in smaller glands (<500 mg) 80 per cent sensitivity was demonstrated. Although the calcium level correlates with the PTH level neither PTH level nor calcium level is predictive of a positive sestamibi scan.