[Chain of errors in laparoscopic appendectomy]. / Cadena de errores en apendicectomía laparoscópica.

BACKGROUND: The urachal cyst is a rare pathology in the adult patient and in general is asymptomatic. The goal of this presentation is to learn of the errors. CLINICAL CASE: A 22 year old female with clinical diagnosis of acute appendicitis was taken to surgical management. Laparoscopy confirmed the diagnosis. Laparoscopic appendectomy was performed uneventfully. Four weeks in the postoperative period the patient developed reddening and softening in the left surgical wound which was a trocar incision. The initial diagnosis was a granuloma which was removed surgically twice. A fistulogram and abdominal CT scan were negative. Finally, we decided to perform a laparatomy trought the same incision and we found an infected urachal cyst, which was excised. A retrospective analysis of the laparoscopic appendectomy shows the urachal cyst and the perforation by the trocars. CONCLUSION: an inadequate process in the laparoscopic vision, in the diagnosis and technical errors were the cause of this chain of errors and a major temporal damage to this patient. An optimal laparoscopy would have detected the urachal cyst and treated of the two pathologies simultaneously. An adequate trocar placement would not have perforated the urachal cyst and therefore there would have been no postoperative symptoms. Finally open appendectomy could have avoided this chain of errors.

Resultados de la aplicación de la lista de verificación quirúrgica en 60 pacientes / Results of applying the surgical checklist in 60 patients

Objetivo: Evaluar los resultados de la aplicación de la lista de verificación quirúrgica en todos los pacientes sometidos a cirugía por nuestro equipo de trabajo. Sede: Institución médica privada. Diseño: Estudio clínico prospectivo, transversal, observacional, descriptivo. Análisis estadístico: Porcentajes como medida de resumen para variables cualitativas. Material y métodos: Se aplicó la lista de verificación quirúrgica en 60 pacientes sometidos a cirugía electiva y de urgencia en la especialidad de Cirugía General realizada por el mismo equipo quirúrgico. Se clasificaron los eventos encontrados que alteraron el flujo de la cirugía relacionados con factores ambientales, de tecnología e insumos, trabajo en equipo, entrenamiento y procedimientos y otros. Resultados: En los 60 pacientes en los que se aplicó la lista de verificación se detectaron 36 eventos que alteraron el flujo normal de la cirugía sin impactar en el paciente y, de éstos, 13 fueron cuasifallas. Las cuasifallas detectadas fueron una fuga de Sevorane y fuga de oxígeno en máquinas de anestesia, falta de una aguja de sutura en el conteo final, que se encontró en cavidad, bultos de cirugía mal esterilizados con batas húmedas, falla en engrapadora quirúrgica por mal manejo del personal, engrapadoras erróneas para procedimiento a realizar, paciente bajo bloqueo espinal al que no se le sujetaron los brazos y ocasionó contaminación del campo quirúrgico. Todos estos hechos ocasionaron una disrupción del flujo quirúrgico. Conclusión: La lista de verificación es una herramienta sumamente útil para la reducción de eventos adversos en un procedimiento quirúrgico.

Objective: To assess the results of applying the surgical checklist to all patients subjected to surgery by our surgical team. Setting: Private medical institution. Design: Clinical prospective, cross-sectional, observational, descriptive study. Statistical analysis. Percentages as summary measure for qualitative variables. Material and methods: The surgical checklist was applied to 60 patients subjected to elective and emergency surgery in the General Surgery specialty performed by the same surgical team. We analyzed the events that altered the surgical flow related to environmental, technological factors, as well as those concerning supplies, team work, training, procedures, and others. Results: In the 60 patients in whom the surgical checklist was applied, 30 events were detected that altered the normal flow of the surgery, without having an impact on the patient. Of these, 13 were quasi-failures. The detected quasi-failures were a Sevorane leak, an oxygen leak in the anesthesia machines, missing of a suture needle in the final count, which was then found in the cavity, surgery packs inadequately sterilized with moist dressings, lack of surgical stapler due to wrong handling by the personnel, wrong stapler for the procedure to be performed, patient under spinal block whose arms were not held in place and caused contamination of the surgical field. All these events caused disruption of the surgical flow. Conclusion: The surgical checklist is a very useful tool to reduce adverse events in a surgical procedure.