The impact of accurate documentation of parotid tumor operative reports on secondary surgical procedure.

Abstract

Objective: To develop a comprehensive operative report schema based on the accuracy of primary operative reports (OpR) assessed on a department's experience with parotid gland tumor re-operations.

Design: Retrospective cross-sectional study.

Setting: A tertiary referral center, the Department of Otolaryngology and Laryngological Surgery, Poznan University of Medical Sciences, Poland from 2008 to 2017.

Subjects: Out of 1154 surgeries, 71 patients underwent reoperation. Their OpR were categorized into accurate and non-accurate, and re-operation field and re-operation course were categorized as anticipated or unanticipated, according to defined criteria.

Intervention: None Main outcome measures: The impact of accuracy of the first OpR on re-operation course.

Results: In this series, OpR were 39% (14/36) accurate, 61% (22/36) non-accurate. Re-operation fields were 16% (11/71) anticipated, 37% (26/71) unanticipated. Re-operation courses were 37% (26/71) anticipated, 63% (45/71) unanticipated. An anticipated re-operation course followed 20% (5/26) of accurate and 20% (5/26) of non-accurate primary OpR. An unanticipated re-operation course followed 20% (9/45) of accurate and 40% (18/45) of non-accurate OpR. There is no significant relationship between the re-operation course and accuracy of the first OpR (Chi2(1)=0.69; p=0.40466). The most common variable that affected non-accuracy of the OpR was facial nerve function after surgery (6/12).

Conclusions: The operative report should be based on clear criteria, robust classification and comprehensive protocol. This will improve follow-up and facilitate the planning of re-operation.