Patient Safety in Surgery最新文献

Background: Bile duct injuries following laparoscopic cholecystectomy are rare but serious complications. Timely diagnosis and optimal management remain challenging. Classification systems for bile duct injuries may facilitate diagnosis, guide treatment, and improve outcomes, however their clinical use is limited. This study systematically evaluated existing classification systems and assessed their applicability to all types of injuries. Based on this analysis, a new classification system for acute lesions was developed.

Methods: The database of the German Arbitration Board for medical liability issues was queried to identify cases involving bile duct injuries following a cholecystectomy (1990-2021). For each patient, the anatomical location, extent of injury, and therapeutic approach were documented. Injuries were categorized according to 11 published classification systems and a newly developed classification system. The ability to categorize bile duct injuries of all systems was assessed.

Results: A total of 106 bile duct injuries were identified. The common bile duct was the most frequently injured structure (31.1%), followed by combined injuries (27.4%), and injuries of the common hepatic duct (17.9%). In 13.2% of cases, an artery was injured in addition to the bile duct lesion. Only 30.2% of bile duct injuries were detected intraoperatively. The most frequently performed techniques were biliodigestive anastomosis (34.4%), direct bile duct anastomosis (31.3%), and leakage closure with stitches (28.1%). None of the 11 existing classifications could categorize all cases; the best-performing systems (Amsterdam, Hannover) classified 82-86%. In contrast, the new Brandenburg Acute Bile Duct Injury (BABD) Classification was able to categorize 99% of the injuries.

Discussion: Current classification systems fail to categorize all acute bile duct injuries following cholecystectomies. The BABD Classification, which is based on the anatomical location and extent of injury, allows systematic categorization of all documented acute bile duct lesions and may improve diagnostic clarity, treatment planning, and comparability in future studies.

Background: In low-resource countries, the incidence of lower extremity long-bone fractures exceeds that in high-resource countries due to higher rates of motor vehicle collisions (MVCs). This situation is worsened by limited resources for adequate care, resulting in significant health and economic impacts. Locked intramedullary nailing (IMN) is a widely accepted treatment for lower extremity fractures, but it carries risks of complications, which have not been well-studied in low-resource settings. Considering the resource differences between high- and low-resource settings, local research is essential for identifying modifiable factors to prevent complications. This study investigated the predictors of complications after IMN with "Surgical Implant Generation Network" (SIGN) nails (Richland, WA, USA) for lower extremity fractures in a low-resource setting.

Methods: A secondary analysis was performed on prospectively collected data from 666 fractures in 603 patients treated with SIGN nails at a mission teaching hospital in southwestern Nigeria between July 2014 and June 2024. The mean age was 43.2 years, and 65.7% of the patients were male. Fractures meeting the inclusion criteria were classified as with or without complications. Two-thirds (66.8%) were femur fractures, and 33. 2% were tibia fractures. Univariate and binary logistic regression analyses identified significant predictors of complications.

Results: The overall complication rate was 11.7%, with infection and non- union being the most common. The mortality rate was 1.1%. Independent predictors of complications included injury mechanism (p = 0.033), fracture age (p = 0.003), fracture type (p < 0.001), prior treatment elsewhere (p = 0.007), and surgery duration (p = 0.004). Fractures resulting from MVCs, older fractures, and open fractures showed higher complication rates. Each additional 30 min of surgery increased the odds of complications by 34% (95% CI, 1.003-1.017).

Conclusion: This study shows that IMN with SIGN nails is an effective treatment for fractures in low-resource settings. However, challenges remain, especially with open fractures and delayed treatment. Prioritizing timely surgery, improving infection control, and enhancing surgical efficiency are essential for better outcomes. The findings inform strategies for improvement and highlight the need for further research to develop evidence-based guidelines for IMN in low-resource environments.

Background: Re-exploratory laparotomy in obstetrics and gynecology is a serious and challenging surgical event associated with significant morbidity and mortality. Understanding its incidence, indications, and outcomes is crucial for improving patient care and surgical safety. This study presents a comprehensive analysis of re-exploratory laparotomies over a 10-year period in a major tertiary care center.

Methods: A retrospective cohort study was conducted on all patients who underwent re-exploratory laparotomy following obstetric or gynecological surgery between 2014 and 2024. Data on patient demographics, primary surgery, indications for re-exploration, time to re-intervention, procedures performed, and postoperative outcomes were collected and analyzed. Statistical analysis was performed using descriptive statistics, chi-square tests, and t-tests to identify significant associations.

Results: A total of 117 cases of re-exploratory laparotomy were identified. The mean age of patients was 31.8 ± 7.0 years. The most common primary surgeries were Cesarean Sect. (46.2%) and total abdominal hysterectomy (23.1%). The leading indications for re-exploration were postpartum hemorrhage (26.5%), muscle hematoma (20.5%), and burst abdomen (17.1%). The mean time to re-exploration was 4.7 ± 2.7 days. The overall mortality rate was 8.5%, and the postoperative complication rate was 46.2%. No significant association was found between the level of emergency and patient outcome (p = 0.637).

Conclusion: Re-exploratory laparotomy remains a critical event in obstetric and gynecological practice, with hemorrhage and postoperative wound complications being the primary drivers. This study highlights the need for meticulous surgical technique, early recognition of complications, and prompt intervention to improve patient outcomes. Further research is needed to identify high-risk patient groups and optimize management strategies.

Background: Surgical safety checklists are essential for reducing errors and improving outcomes, but consistent, full-phase adherence remains suboptimal. Traditional paper-based systems can disrupt workflow and limit team engagement. Voice-enabled solutions offer potential to improve compliance while preserving sterile conditions and communication flow in the operating room (OR).

Methods: This study aimed to develop and evaluate a prototype voice-controlled digital assistant for surgical checklists - referred to as 'VoiceCheck' - with a focus on usability, technical performance, and feasibility in real-world clinical settings. VoiceCheck guides clinical teams through the "Sign In", "Time-out", and "Sign Out" phases of the surgical checklist using voice commands and speech transcription. The system operates offline, incorporating Rhasspy for intent recognition and Whisper for speech-to-text transcription. Twelve surgical team members participated in a field evaluation, completing structured tasks alongside routine workflows. Usability was assessed using the System Usability Scale (SUS) and a custom questionnaire. Technical evaluations tested Whisper V2 and V3 under quiet and noisy conditions, and Rhasspy's intent and wake word recognition across 1'125 commands in two environments (noisy, quiet).

Results: Participants rated usability positively (SUS median score 76.04). Whisper V3 achieved 90.7-97.3% transcription accuracy, outperforming V2 in noisy settings. Rhasspy recognized intents with 92.8-94.8% accuracy and maintained a low false-positive rate. VoiceCheck functioned reliably offline and was preferred with a conference microphone for multi-user interaction.

Conclusion: VoiceCheck demonstrates feasibility for voice-assisted checklist execution in surgical settings. It was well accepted by users and performed reliably under realistic conditions. Further research should explore clinical integration, workflow impact, and multilingual capabilities.

Background: Awake colorectal surgery is an alternative to general anesthesia, especially in high-risk patients with significant cardiopulmonary comorbidities. Continuous segmental spinal anesthesia offers stable intraoperative conditions while avoiding the complications of cardio depressant effects, airway manipulation and sedation. Despite its advantages, this approach remains underreported in major colorectal procedures.

Case presentation: We present the case of a 73-year-old male with a history of ischemic cardiomyopathy, chronic heart failure (ejection fraction 25-30%), chronic kidney disease, and pulmonary complications, classified as American Society of Anesthesiologists (ASA) Risk Class V. The patient was admitted to a tertiary hospital in Palestine with a recurrent sigmoid volvulus, and due to the high risk associated with general anesthesia, the surgical, cardiology and anesthesia teams decided for an awake open sigmoidectomy under continuous segmental spinal anesthesia. The patient remained fully conscious and hemodynamically stable throughout the procedure. Postoperative recovery was uncomplicated apart from a superficial wound infection, which was managed conservatively. At six-month follow-up, the patient remained asymptomatic, tolerated a normal diet, had no recurrent bowel obstruction, and showed complete wound healing without late infectious or anastomotic complications.

Conclusion: This case illustrates the feasibility, safety, and potential benefits of awake sigmoidectomy in fragile, multimorbid patients. To our knowledge, it represents the first reported case in Palestine. The successful outcome emphasizes the importance of advanced regional techniques and multidisciplinary collaboration in managing high-risk surgical patients, especially in settings with limited resources.

Introduction: Retained surgical items are rare yet serious complications that may occur despite correct instrument and sponge counts. Surgical sponges remain the most frequently retained items, with gauze marker strand retention being an uncommon mechanism.

Case presentation: A 69-year-old male with severe mitral regurgitation and triple-vessel coronary artery disease underwent mitral valve replacement with coronary artery bypass grafting. All surgical counts were verified as correct at the conclusion of surgery. Postoperative chest radiography, however, revealed two linear radio-opaque foreign bodies near the left lower sternum. Mediastinal re-exploration identified two radio-opaque strands, measuring 3.0 cm and 2.0 cm, attached to the left lower chest wall near the internal mammary artery stump. These were confirmed to be detached marker strands from Raytec gauzes. The patient's recovery was uneventful and he was discharged well.

Conclusion: This case illustrates that retained gauze fragments can occur despite correct counts due to fragmentation of radiopaque markers. Surgeons and operating room nurses should inspect gauzes for integrity, maintain vigilance when manipulating sponges in confined operative fields, and consider adjunct technologies such as radiofrequency or barcode tracking. In high-risk surgeries, postoperative imaging may be warranted even with accurate counts to ensure patient safety.