34th Annual Scientific Meeting proceedings

Adverse events are unexpected clinical developments experienced by the patient and caused by the treatment provided and not the underlying disease.¹  In veterinary medicine, these are often characterized within the broad category of complications instead of adverse events.²  An error is defined as the failure of a planned action to be completed as it was intended or the use of the wrong plan to achieve the desired endpoint.³  Technical errors in surgery are adverse events caused by errors in operative technique, including errors of execution (manual error) or errors of planning (judgement or knowledge error).¹  The incidence and prevalence of technical errors in human medicine is not as well documented as desired.  Surrogate measures include rating of surgical skills, analysis of surgical malpractice claims, and prospective benchmarking of surgical outcomes.^3-6 

A wide variety of technical skills are seen among surgeons.  Higher scores for technical skills in human surgery are related to improved patient outcomes, as seen by decreased rates of any complications, fewer unplanned reoperations, and lower serious morbidity or mortality.^5,6 Technical skills account for 25-30% of the variability in complication rates for a surgical procedure.⁵ Specific to human gastrointestinal surgery, anastomotic leak rates, repeat celiotomy, and surgical hemorrhage are associated with technical execution of the surgery.^5,6

Causes of technical errors in human surgery have been associated with lack of specialization, low surgical volumes, inexperienced surgeons or trainees, fatigue, complicated surgeries, and patient comorbidities.³  Analysis of surgical malpractice claims indicates that almost 75% of technical errors involved attending surgeons operating within their area of expertise and 84% of these errors occurred in routine surgeries not requiring advanced training or expertise.³  Patient-related complexities contributed to 61% of technical errors, including difficult or unusual anatomy (25%), reoperation (20%), urgent or emergency surgeries (17%), or comorbidities (6%).³ This means that while expanding surgical training and honing skills acquisition must be implemented to reduce technical errors in surgery, training to improve decision-making and surgical performance in routine operations for high-risk patients and atypical circumstances should be emphasized in all surgeons.³  In absence of real-time and objective assessments of surgical ability, it is also important that every surgeon reflects on their errors and analyzes their own performance to improve their surgical technique and patient outcomes.¹

The occurrence and incidence of technical errors in equine gastrointestinal surgery has not been directly reported.  Similarly, there is no published benchmarking of expected outcomes for equine colic surgery, which is one of the goals of the INCISE project by the University of Liverpool.⁷ One report described intraoperative complications (interpreted as surgical error) as occurring in 4% in all colic surgeries, including hemorrhage from mesenteric vessels (2%), iatrogenic intestinal rupture (1.7%) and gross contamination (0.3%).⁸  Certain surgical errors are more prevalent with certain types of lesions, such as rupture of the portal vein with epiploic foramen entrapment and iatrogenic intestinal rupture with obstructive large colon lesions.⁹  However, technical errors may manifest as postoperative morbidity, including need for repeat celiotomy and postoperative mortality. 

Early postoperative complications that could be attributed to surgical error, at least in some surgeries, include postoperative reflux, fever, peritonitis, and postoperative hemoperitoneum.^8,10-12 Some of these complications are associated with the need for repeat celiotomy.  It has been estimated that at least 40-45% of repeat celiotomies are required subsequent to surgical errors.^9,13,14  Repeat celiotomy findings associated with surgical error include anastomotic obstruction (impaction, kinking), anastomotic leakage, intestinal ischemia, and peritonitis.^9,11,14-18  Postoperative mortality is associated with postoperative colic, postoperative reflux, and sepsis/SIRS, which can a consequence of anastomosis problems, progression of ischemia, and peritonitis.

Although all surgical errors are problematic, the ones to be most mindful of are the errors that are relatively common with life-threatening consequences.  This would include prevention of iatrogenic gastrointestinal rupture, accurate identification of intestinal ischemia, secure ligation of mesenteric vessels and avoidance of inadvertent vascular trauma, and use of anastomotic techniques to maximize lumen size, appose securely, and avoid kinking.  This not only references prevention of errors of execution (manual errors), but also errors of planning (knowledge and judgement).  Risk of iatrogenic gastrointestinal rupture can be reduced by generous abdominal incisions, decompression of the large colon by whatever means possible, and gentle manipulation, including copious intraabdominal fluids.⁹ Mesentery should be handled gently and without tension to avoid trauma.  All vessels within the field of transection should be securely ligated and inspected for signs of hemorrhage.  Anastomoses should be constructed carefully with diligent attention to optimal technique.  If strangulated intestine is deemed viable and not resected, those horses should be closely monitored and early repeat laparotomy should be considered if postoperative colic or reflux occur. 

As part of continued improvement, it is essential for surgeons to individually reflect on their surgical performance, including self-assessment and critique of skills and identification of errors.¹  It is also important to continually self-monitor abilities and outcomes throughout a surgeon’s career,^16,19 and to be mindful that certain circumstances, particularly those with difficult anatomy, repeat celiotomies, and urgent/emergent surgeries, are more prone to technical errors.³

References

1. Fesco AB, Szasz P, Kerezov G, Grantsharov TP.  The effect of technical performance on patient outcomes in surgery. A systematic review. Ann Surg. 2017;265:492-501.
2. Gandini M, Cerullo A, Giusto G.  Scoping review: occurrence and definitions of postoperative complications in equine colic surgery. Equine Vet J. 2023;55:563-572.
3. Regenbogen SE, Greenberg CC, Studdert DM, Lipsitz SR, Zinner MJ, Gawande AA.  Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients.  Ann Surg. 2007;246:705-711.
4. Rebasa P, Mora L, Luna A, Montmany S, Vallverdu H, Navarro S.  Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in general surgery.  World J Surg. 2009;33:191-198.
5. Stulberg JJ, Huang R, Kreutzer L, Ban K, Champagne BJ, Steele SR, Johnson JK, Holl JL, Greenberg CC, Bilimoria KY.  JAMA Surg. 2020;155:960-968.
6. Gruter AAJ, Van Lieshout AS, van Oostendorp SE, Henckens SPG, Ket JCF, Gisbertz SS, Toorenvliet BR, Tanis PJ, Bonjer HJ, Tuynman JB.  Video-based tools for quality assessment of technical skills in laparoscopic procedures: a systematic review. Surg Endosc. 2023;37:4279-4297.
7. Archer DC, Cullen M, Ireland JL, Mair TS.  The international colic surgery audit (INCISE-2): patient and operative features and benchmarks.  Equine Vet Educ. 2024;36(s13):35.
8. Mair TS, Smith LJ.  Survival and complication rates in 300 horses undergoing surgical treatment of colic. Part 1: short-term survival following a single laparotomy. Equine Vet J. 2005;37:296-302.
9. Freeman DE, Bauck AG.  Repeat celiotomy – current status. Vet Clin Equine. 2023;39:325-337.
10. Freeman KD, Southwood LL, Lane J, Lindborg S, Aceto HW.  Post operative infection, pyrexia and perioperative antimicrobial drug use in surgical colic patients.  Equine Vet J. 2012;44:476-481.
11. Gray SN, Dechant JE, LeJeune SS, Nieto JE.  Identification, management and outcome of postoperative hemoperitoneum in 23 horses after emergency exploratory celiotomy for gastrointestinal disease.  Vet Surg. 2015;44:379-385.
12. Pye J, Espinosa-Mur P, Roca R, Kilcoyne I, Nieto J, Dechant J.  Preoperative factors associated with resection and anastomosis in horses presenting with strangulating lesions of the small intestine.  Vet Surg. 2019;48:786-794.
13. Sinha AK, Robertson JT, Reeves MJ.  The role of surgical technique in the need for early relaparotomy in the horses.  Vet Surg. 1995;24:440.
14. Mair TS, Smith LJ.  Survival and complication rates in 300 horses undergoing surgical treatment of colic. Part 4: early (acute) relaparotomy. Equine Vet J. 2005;37:315-318.
15. Dunkel B, Mair T, Marr CM, Carnwath J, Bolt DM.  Indications, complications, and outcome of horses undergoing repeated celiotomy within 14 days after the first colic surgery: 95 cases (2005-2013).  J Am Vet Med Assoc. 2015;246:540-546.
16. Brown JA, Holcombe SJ, Southwood LL, Byron CR, Embertson RM, Hauptmann JG.  End-to-side versus side-to-side jejunocecostomy in horses: a retrospective analysis of 150 cases.  Vet Surg. 2015;44:527-533.
17. Findley JA, Salem S, Burgess R, Archer DC.  Factors associated with survival of horses following relaparotomy.  Equine Vet J. 2017;49:448-453.
18. Bauck AG, Easley JT, Cleary OB, Graham S, Morton AJ, Rotting AK, Smith AD, Freeman DE.  Response to early repeat celiotomy in horses after a surgical treatment of jejunal strangulation.  Vet Surg. 2017;46:843-850.
19. Patchen Dellinger E, Pellegrini CA, Gallagher TH.  The aging physician and the medical profession: a review.  JAMA Surg. 2017;152:967-971.