Technical and operative errors

Technical and operative errors

In surgery , the person rather than systems approach empha - sises the accountability of the surgeon, who, unlike colleagues in other medical disciplines, when operating carries specific responsibilities. During a surgical procedure, for example, there may be a specific action that, of itself, may be the error, such as inadvertent injury to the common bile duct during a cholecystectomy ( Figure 15.3 ) . The practical value of this kind of interpretation is that, provided latent conditions are excluded, it gives a sense of responsibility to the surgeon and it may also help to point to the most e ff ectiv e pathway for reme diation, by counselling or retraining, as against reassessing the system and putting in place further safeguards. Central to operative performance is proficiency , an acquired state, honed by sound teaching, practice and repeti - tion, by which a sur geon consistently performs operations with good outcomes. In cognitive psychology , high surgical profi - ciency is a state of automatic unconscious processing, with the execution being e ff ortless , intuitive and untiring, as opposed to non-proficient execution, which is characterised by conscious control processing, requiring constant a ttention and resulting in slow , deliberate execution and inducing fatigue. The transi - tion from one state to the other is better known as the ‘learning curve’ and is reflected in the hierarchal pyramid of competence ( Figure 15.4 ). This should not carry negative connotations f or trainee surgeons, who might be at the conscious processing stage but still perform a perfectly good operation, although it might take longer and be more tiring. Failures in operative technique include: /uni25CF cognitive errors of judgement, such as late conversion of a di ffi cult laparoscopic procedure into an open one; /uni25CF procedural , when the steps of an operation are not fol - lowed or are omitted; /uni25CF executional , when, for example, too much force is used, which may result in damage that may or may not have consequences; /uni25CF misinterpretation of anatomy/pathology , which is compounded by minimal access surgery with the limita - tions of a two-dimensional image; /uni25CF misuse of instrumentation, such as with energised dissec - - tion modalities (e.g. diathermy); /uni25CF missed iatrogenic injury either at the time of surgery or diagnosed late.

Figure 15.2 Axial (a) and coronal (b) magnetic resonance images demonstrating a well-de /f_i ned abdominal mass with whorled stripes in a /f_l uid- /f_i lled central cavity (arrows). This 60-year-old woman had had an abdominal hysterectomy 10 years previously and presented with pyrexia and /f_l ank pain. The cause was due to the late presentation of a retained surgical swab. Figure 15.3 Endoscopic retrograde cholangiopancreatography radio graph showing an iatrogenic bile duct injury.

Unconscious Right intuition competence Conscious competence Right analysis Conscious incompetence Wrong analysis Unconscious incompetence Wrong intuition Figure 15.4 Hierarchy of competence.