Occurrence Of Intraoperative Complications Research Articles

Quality of inguinal hernia operative reports: room for improvement

Operative reports (ORs) serve as the official documentation of surgical procedures. They are essential for optimal patient care, physician accountability and billing, and direction for clinical research and auditing. Nonstandardized narrative reports are often of poor quality and lacking in detail. We sought to audit the completeness of narrative inguinal hernia ORs. A standardized checklist for inguinal hernia repair (IHR) comprising 33 variables was developed by consensus of 4 surgeons. Five high-volume IHR surgeons categorized items as essential, preferable or nonessential. We audited ORs for open IHR at 6 academic hospitals. We audited 213 ORs, and we excluded 7 femoral hernia ORs. Tension-free repairs were the most common (82.5%), and the plug-and-patch technique was the most frequent (52.9%). Residents dictated 59% of ORs. Of 33 variables, 15 were considered essential and, on average, 10.8 ± 1.3 were included. Poorly reported elements included first occurrence versus recurrent repair (8.3%), small bowel viability in incarcerated hernias (10.7%) and occurrence of intraoperative complications (32.5%). Of 18 nonessential elements, deep vein thrombosis prophylaxis, preoperative antibiotics and urgency were reported in 1.9%, 11.7% and 24.3% of ORs, respectively. Repair-specific details were reported in 0 to 97.1% of ORs, including patch sutured to tubercle (55.1%) and location of plug (67.0%). Completeness of IHR ORs varied with regards to essential and nonessential items but were generally incomplete, suggesting there is opportunity for improvement, including implementation of a standardized synoptic OR.

Low-pressure pneumoperitoneum could decrease postoperative alterations of hemodynamic variables and pulmonary function tests after laparoscopic cholecystectomy

Objectives: To evaluate the impact of pneumoperitoneum on pulmonary fimctions, hemodynamic variables and frequency and intensity of shoulder tip pain (STP) in patients undergoing laparoscopic cholecystectomy (LC). Patients & methods: Fifty chronic calcular cholecystitis patients were allocated to high­ pressure (HP) group (13-15 mmHg) and low-pressure (LP) group (9-11 mmHg). Mean arterial pressure (MAP), and heart rate (HR) measurements were obtained before (I'1), after induction of anesthesia (I'2), 5 min. before (T3), after insufflation (T4), 5 min. after tilting in reverse Trendelburgposition (T5) and after exsu.fflation of C02 (T6). Duration of surgery, occurrence of intraoperative complications and conversion to laparotomy, time till first ambulation, first oral intake and length of postoperative (PO) hospital stay were recorded. Severity of PO STP was assessed using visual analogue scale at 3, 6, 12, 24, and 48 hours. Forced vital capacity (FVC),forced expiratory volume in 1 sec (FEVJ) and FEVJ/FVC ratio were estimated 24 hours prior to and after surgery. Results: All patients passed smooth intraoperative course without complications or conversion to laparotomy. Mean operative data showed non-significant difference between both groups. At T4 and T5 HR and MAP measurements were significantly higher in HP group despite the significant difference compared to other measures in both groups. Twenty-three patients had STP with significantly higher frequency and intensity in HP group.Mean duration till request of analgesia was significantly longer in LP group. Pneumoperitoneum altered PO pulmonary function tests compared to preoperative values with significantly altered FEV1 evaluated as the percentage of change in HP group. Conclusion: Pneumoperitoneum irrespective of the pressure used affects pulmonary function tests andinduces hemodynamic changes with precipitation ofSTP,· however LP allowed significant amelioration of these effects despite that it could not abolish it, so it allows getting the advantages of laparoscopic surgery with minimal hazards.

Complication rate and risk factors for intraoperative complications in resident-performed phacoemulsification surgery

To determine the complication rate and risk factors for intraoperative complications in resident-performed phacoemulsification surgery at a tertiary care center during the first 100 surgeries. Retrospective chart review of the first 100 performed phacoemulsification cases of six consecutive residents. Posterior capsule tear, vitreous loss, and dislocation of lenticular fragments into the vitreous were defined as intraoperative complications. Patient characteristics considered risk factors for surgery were identified and correlated with the occurrence of intraoperative complications. Complications occurred in 23 of 600 operations (3.8 %). Surgery was complicated by posterior capsular tear in 23 eyes (3.8 %) with vitreous loss in 17 eyes (2.8 %) and loss of lenticular fragments into the vitreous in seven eyes (1.2 %). Eyes with dense nuclear sclerosis (p = 0.002) and white cataracts (p = 0.019) were associated with a statistically significantly greater incidence of posterior capsular tears and vitreous loss (p = 0.007 and p = 0.027 respectively). An intraocular lens was implanted in 591 eyes as intended. Residents achieve an acceptable complication rate during their initial 100 phacoemulsification cases.

The Effect of Neuromuscular Blockade on Canine Laparoscopic Ovariectomy: A Double‐Blinded, Prospective Clinical Trial

To evaluate the effect of neuromuscular blockade (NMB) on surgical time and various anesthetic variables during laparoscopic ovariectomy in dogs. Prospective, double-blinded, randomized clinical trial. Female dogs (n = 40). Laparoscopic ovariectomy by bipolar electrocoagulation was performed by 1 surgeon using a standardized protocol, where 1 ovary was removed under NMB, and the other without NMB. Surgical and anesthetic (respiratory and circulatory) variables were recorded for predetermined procedural stages and were statistically evaluated. Mean total surgical time was 25.1 ± 6.3 minutes (range, 16-47 minutes). With NMB, mean duration of surgical excision of the ovary (5.7 ± 2.3 minutes) was not significantly changed compared to ovariectomy without NMB (5.9 ± 1.9 minutes). Arterial blood pressure was the only recorded anesthetic variable that significantly changed under NMB (5% decrease). Occurrence of intraoperative complications did not differ. In obese dogs, total surgical time was increased by 22%. Other variables, including occurrence of intraoperative mesovarial bleeding did not influence surgical duration. NMB did not significantly improve laparoscopic ovariectomy times and except for a 5% decrease in arterial blood pressure did not change any of the evaluated anesthetic and surgical variables.

The Pararectus approach for anterior intrapelvic management of acetabular fractures

A new anterior intrapelvic approach for the surgical management of displaced acetabular fractures involving predominantly the anterior column and the quadrilateral plate is described. In order to establish five 'windows' for instrumentation, the extraperitoneal space is entered along the lateral border of the rectus abdominis muscle. This is the so-called 'Pararectus' approach. The feasibility of safe dissection and optimal instrumentation of the pelvis was assessed in five cadavers (ten hemipelves) before implementation in a series of 20 patients with a mean age of 59 years (17 to 90), of whom 17 were male. The clinical evaluation was undertaken between December 2009 and December 2010. The quality of reduction was assessed with post-operative CT scans and the occurrence of intra-operative complications was noted. In cadavers, sufficient extraperitoneal access and safe instrumentation of the pelvis were accomplished. In the patients, there was a statistically significant improvement in the reduction of the fracture (pre- versus post-operative: mean step-off 3.3 mm (sd 2.6) vs 0.1 mm (sd 0.3), p < 0.001; and mean gap 11.5 mm (sd 6.5) vs 0.8mm (sd 1.3), p < 0.001). Lesions to the peritoneum were noted in two patients and minor vascular damage was noted in a further two patients. Multi-directional screw placement and various plate configurations were feasible in cadavers without significant retraction of soft tissues. In the treatment of acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach allowed anatomical restoration with minimal morbidity related to the surgical access.

Predicting safe tonsillectomy for ambulatory surgery

Objectives To assess the safety of tonsillectomy procedure in local setting. Methods Retrospective review of 267 tonsillectomy patients in Tengku Ampuan Afzan Hospital, Malaysia from January 2006 to December 2007. Results Only 2.6% had trauma, 1.1% had difficult intubation, 0.7% had anaesthetic complication and none developed bleeding intra-operatively. Post-operatively, both primary and secondary haemorrhage showed prevalence of 1.9% each, 1.1% patients had infection and 0.4% patients had inability of extubation while another 1.9% had other complications. Duration of post-operative hospital stay was only slightly increased with occurrence of intra-operative complications but not with post-operative complications. Significant increase in risk was observed for both primary haemorrhage (OR: 1.05, 95% CI 1.01–1.09 min, P = 0.020) and respiratory complications (OR: 1.08, 95% CI 1.01–1.16 min, P = 0.024) by 4.5% and 8.3%, respectively, with every 1-min increase in length of surgery. Conclusions The observed low prevalence of complications corresponded with large number of studies denoting safety of tonsillectomy. This may well be increased by appropriately reducing the length of surgery. Although predictors for complications were unable to be determined, it is not advisable for ambulatory tonsillectomy to be performed on OSA patients considering the respiratory complications observed in our setting.

Tubeless percutaneous nephrolithotomy in selected patients: a prospective randomized comparison

To prospectively compare the outcome of standard and tubeless percutaneous nephrolithotomy (PNL) in a selected group of patients with renal stones. Patients with simple, isolated renal pelvis or lower pole caliceal stones and no significant hydronephrosis were randomly enrolled to undergo either standard PNL, in which routine nephrostomy tube was placed at the end of operation, or tubeless PNL. Occurrence of intraoperative complications, total operative time exceeding 2 h, indication for additional access or second-look PNL due to residual stones were exclusion criteria. There were 11 isolated lower pole caliceal stones (mean stone burden: 3.1 cm(2)) and 6 isolated renal pelvis stones (mean stone burden: 2.8 cm(2)) in the tubeless PNL group (n: 17), and 9 isolated lower pole caliceal stones (mean stone burden: 3.4 cm(2)) and 9 isolated renal pelvis stones (mean stone burden: 3.1 cm(2)) in the standard PNL group (n: 18). Mean operation time was 59.6 +/- 9.1 (range: 50-90) min in the tubeless group, and 67.3 +/- 10.1 (range: 60-115) min in the standard PNL group (P > 0.05). Successful stone removal was achieved in all patients, and no significant complication was observed in any case. The mean postoperative analgesic requirement was significantly less in the tubeless group (P < 0.05). Mean hospital stay was 1.6 +/- 0.4 (range: 1-3) days in the tubeless group, and 2.8 +/- 0.9 (range: 2-4) days in the former group (P < 0.05). Our results indicate that tubeless PNL is safe in the management of selected patients and that mean analgesic requirement as well as hospitalization time is diminished with this modification.

Postcataract Endophthalmitis in South India: Incidence and Outcome

To determine the incidence of acute-onset postcataract endophthalmitis, identify risk factors, and determine clinical outcomes in a tertiary eye care center in South India. Retrospective, interventional, observational case series. All patients who underwent cataract extraction from January 2002 to December 2003 at Aravind Eye Hospital, Madurai. The records of patients with acute endophthalmitis after cataract surgery were reviewed. Acute-onset postcataract endophthalmitis, incidence rates, risk factors, organisms cultured, and visual acuity outcomes after treatment. During the study period, 36072 cataract surgeries were performed; these included 22294 cases of phacoemulsification and 9503 cases of extracapsular cataract extraction. A total of 19 eyes developed acute endophthalmitis after cataract surgery (average 2-year incidence, 0.05%). Ten cases were culture positive (average 2-year incidence, 0.03%). In multivariate analysis, increased risk of endophthalmitis was associated with intraoperative complications, such as posterior capsular rent and vitreous loss (relative risk [RR], 6.57; 95% confidence interval [CI], 1.5-28.5; P = 0.05) for all endophthalmitis cases, age >60 years for culture-positive endophthalmitis cases (RR, 6; 95% CI, 0.7-47.8; P = 0.04), and an extracapsular cataract extraction technique for culture-positive endophthalmitis cases (RR, 4.9; 95% CI, 1.2-19.3; P = 0.001). After follow-up of 37 days, 5 (29.41%) of the 17 patients achieved a best-corrected visual acuity (BCVA) of 20/40, and the remaining 7 (32.3%) had a BCVA better than 20/200. Of the culture-positive cases, Nocardia species was the most common organism isolated, accounting for more than half of these cases (6/10 [60%]). This study found the incidence of acute postoperative endophthalmitis after cataract surgery to be 0.05%. Extracapsular cataract extraction technique and the occurrence of intraoperative complications are major risk factors for developing endophthalmitis. Visual outcome after endophthalmitis was generally poor. Nocardia is a lesser-known but virulent organism causing endophthalmitis, the management of which still poses a therapeutic dilemma.

First Prize: Factors Affecting Blood Loss During Percutaneous Nephrolithotomy: Prospective Study

Bleeding is a major concern during percutaneous nephrolithotomy (PCNL), especially with the use of multiple tracts. This prospective study aimed to identify factors affecting blood loss during PCNL. Data were collected prospectively from 236 patients undergoing 301 PCNL procedures at our institute since June 2002. Blood loss was estimated by the postoperative drop in hemoglobin factored by the quantity of any blood transfusion. Various patient-related and intraoperative factors were assessed for association with total blood loss or blood transfusion requirement using stepwise multivariate regression analysis. The average hemoglobin drop was 1.68 +/- 1.23 g/dL. Stepwise multivariate regression analysis showed that the occurrence of operative complications (P < 0.0001), mature nephrostomy tract (P < 0.0001), operative time (P < 0.0001), method of access guidance (fluoroscopy v ultrasound) (P = 0.0001), method of tract dilatation (P = 0.0001), multiple (> or =2) tracts (P = 0.003), size of the tract (P = 0.001), renal parenchymal thickness (P = 0.05), and diabetes (P = 0.05) were significant predictors of blood loss. The overall blood transfusion rate for all patients was 7.9%. Preoperative hemoglobin, multiple tracts, stone size, and total blood loss were significant in predicting perioperative blood transfusion requirement. Factors such as age, hypertension, renal insufficiency, urinary infection, the degree of hydronephrosis, stone bulk, and the function of the ipsilateral renal unit did not have any effect on the blood loss. Technical factors such as the operating surgeon and the calix of entry also did not affect the blood loss. Diabetes, multiple-tract procedures, prolonged operative time, and the occurrence of intraoperative complications are associated with significantly increased blood loss. Atrophic parenchyma and past ipsilateral intervention are associated with reduced blood loss. On the basis of this evidence, maneuvers that may reduce blood loss and transfusion rate include ultrasound-guided access, use of Amplatz or balloon dilatation systems, reducing the operative time, and staging the procedure in cases of a large stone burden or intraoperative complications. Reducing the tract size in pediatric cases, nonhydronephrotic systems and those with a narrow infundibulum, and secondary tracts in a multiple-tract procedure may also reduce blood loss during PCNL.

Vitrectomy for Premacular Fibroplasia: Prognostic Factors, Long-term Follow-up, and Time Course of Visual Improvement

Two hundred seventy eyes with premacular fibroplasia consecutively treated by pars plana vitrectomy and membrane peeling were reviewed. This study is among the largest series with long-term follow-up reported to date. Visual improvement of two or more lines was achieved in 43% of eyes at 6 to 12 months, in 54% at 1 to 2 years, in 60% at 2 to 3 years, and in 58% at 3 to 5 years. Overall, complications occurred in 34 eyes (13%). Cataract progression after vitrectomy was noted in 106 (57%) of phakic eyes at 3 to 5 years, and 43 of these eyes underwent subsequent cataract extraction. Mean time to best visual acuity after vitrectomy was slightly less than 1 year for all eyes unless they had cataract worsening with subsequent cataract extraction (1.9 years). Significant factors affecting visual outcome were: preoperative lens status, visual acuity before vitrectomy, duration of preoperative symptoms of distortion and/ or blurred vision, and the occurrence of intraoperative complications.