Surgery in difficult or
problematic settings
Dimitrios Tsiftsis
General Surgeon
1st Surgical Department
General Hospital of Nikea, Greece
Difficult settings
John Hopkins Hospital
But even there difficulties exist
• Massachusetts General Hospital fined $1 million
on March 03, 2011
• Medication Overdose: Boston Medical
Malpractice Lawsuit Claims Massachusetts
General Hospital Gave 76-Year-Old Woman the
Wrong Blood Thinner
• In 2008, the most recent year with complete
records, 116 wrong-site surgeries, up from 93 in
2007, were recorded by the Joint Commission
Any setting can become difficult or
problematic
• Sudden spike of incoming surgical cases
– Number
– Severity
– Endemic outbreaks
• Sudden drop in hospital facilities
– Budget cuts
– Personnel cuts
– Malfunctioning equipment (eg. CT)
Pitfalls in the Evaluation and Management of the
Trauma Patient
Curr Probl Surg 2007;44:778-833
Examples of Potential Problems
(Failures) in Team Dynamics
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Error in patient management due to
incomplete information (PE, labs, physiology)
Errors in communication (plans, instruments,
procedures)
Errors in workload distribution (Inexperience,
underpowered, Distraction, Lack of
supervision)
Conflict resolution issues
Prevention filters
• Date:
– 24/11/1963
• Lee Harvey Oswald:
– Shot
• Transport time:
– 10 min
• Surgeon:
– G.Tom Shires reports
3 liters of blood
Shattered spleen
Inferior vena cava,
kidney, liver, hole
Shattered pancreas
Aortic bleeding
Superior mesenteric artery
sheared off aorta
Any operation can become difficult or
problematic
• Task execution errors: In surgery, this could include
technical slips and psychomotor errors (eg, bowel injury
during laparotomy), and judgment or perceptual errors
causing a technical error such as laparoscopic bile duct
injury.
• Procedural errors: Errors involving deviation from existing
practice pattern or protocol (eg,failure to administer
preoperative antibiotics for a bowel case).
• Communication errors: Communication of incorrect data,
failure to communicate important data, delayed
communication of critical data, etc.
• Decision errors: Errors in judgment related to patient
management
Know your capacities
Know the enemy and know yourself, and you
can fight a hundred battles with no danger of
defeat
Sun-Tzu
• Management of the alert: activation of the Hospital
Emergency Response Plan
• Hospital Incident Management System--Hospital Incident
Command Group (ICG)
• The reception of patients in MCI and external traffic flow-- and
ambulatory treatment (OPD)
• Emergency Department and internal traffic flow
• Management of human resources
• Supplement Emergency Response Plans (SERPs) of the
departments and units of the hospital
• Logistics and supplies
• Management of information--risk communication-communication systems and --Health Information System
(HIS)
• Pharmacy: essential medicines, vaccines and preventive
equipment and other supplies such as disinfectants
• Security
• Maintenance and safety--essential technical services-lifelines--rehabilitation of critical equipment
Pay someone to do it for you
The greatest mistake in the treatment of
diseases is that there are physicians for the body
and physicians for the soul,
although the two cannot be separated
Plato
Planning
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Know your institution capacities
Pre-establish patient transfer protocols
Triage carefully
Stash critical drugs and equipment
Surgeons on call with emergency surgery
training
Modern surgeon balances
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Equipment
Other disciplines
Drugs
ICU
Personnel
Cost
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Case load
Case severity
Emergencies
Mass events
Do not move the disaster area from the
ER
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Radiology
Surgery
Laboratories
Floor
ICU (?)
Triage
Indications for and Techniques of
Laparotomy
D. Demetriades, G. Velmahos
• The full appreciation of the patient's picture,
taking into account all available information
provided by clinical examination, radiographic
findings, and laboratory tests is more useful than
the adherence to rigid protocols that prevent
individualization
• However, the two signs, which remain absolute
indications for laparotomy following penetrating
or blunt abdominal trauma are peritonitis and
hemodynamic instability
Trauma, 6th Edition, 2008 McGraw-Hill
I learned a long time ago that minor
surgery is when they do the operation on
someone else, not you
Bill Walton
Once in the OR
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Intention to cure
Safe
Fast
Plan B
Damage control surgery
The concept of ‘damage control’ (also known as ‘staged laparotomy’,
‘Bailout surgery’) has as its objective the delay in imposition of
additional surgical stress at a moment of physiological frailty.
This is a technique where the surgeon minimizes operative time and
intervention in the grossly unstable patient. The primary reason
is to minimize hypothermia and coagulopathy, and to return
the patient to the operating room in a few hours after stability has
been achieved in an ICU setting. Enough appropriate surgery has to
be carried out in order to minimize activation of the inflammatory
cascade and the consequences of SIRS and organ dysfunction.
The concept of staging applies both to routine and to emergency
procedures, and can apply equally well in the chest, pelvis and neck
as in the abdomen.
Kenneth D Boffard ed., Manual of Definitive Surgical Trauma Care 2nd ed. Edward Arnold (Publishers) Ltd, England. 2007
Principles
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Shorten operation time
Employ damage control surgery
Get patient to ICU
Warm patient and correct coagulopathy
Prepare yourself and your team
Re-operate for definitive treatment
Shorten operation time
Shorten time in surgery
• Damage control surgery
• Source control surgery
• Restoration of physiology over restoration of
anatomy
Physiologic Guidelines
That Predict the Need for Damage
Control
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Hypothermia <34C
Acidosis Ph<7.2
Serum bicarbonate <15mEq/L
Transfusion >4000ml of RBC
Transfusion >4000ml of blood products
Intraoperative volume replacement >12000ml
Clinical evidence of intraoperative coagulopathy
Mohr A., Asensio J., Garcia L. et al. Guidelines for the institution for Damage Control in trauma patients,
International Trauma Care, 2005
Τ<34οC
pH<7,2,
lactate>5mmol/lt,
Coagulopathy
Complete operation in 60’
Transfer to ICU in<90’
• Control hemorrhage - Ligate all large bleeding
vessels
• Explore the abdomen
• Contamination control
• Pack the abdomen
• Temporarily close the abdomen
• Transfer to the ICU
Timeframe
Abdominal Vessel Ligation and
Expected Complications
Cirocchi R, Abraha I, Montedori A, Farinella E, Bonacini I, Tagliabue L,
Sciannameo F. Damage control surgery for abdominal trauma. Cochrane
Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007438. DOI:
10.1002/14651858.CD007438.pub2
Evidence that supports the efficacy of DCS with
respect to traditional laparotomy in patients
with major abdominal trauma is limited
He who fights and runs away will live to fight
another day
Demosthenes
Damage control essential equipment
Basic:
• Abdominal, vascular, and chest instruments (including sternal saw)
Damage control essentials:
• Packs
• Shunts (sterile plastic conduits)
• Balloon catheters (large Foley of various sizes with 30 cc balloons)
• Sterile silastic bags
• Adhesive plastic
• Hemostatic agents
• Suction drains
Hoey B., Schwab C., Damage control surgery. Scan J Surg, 2002;91: 92–103
Damage control surgery
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No high-tech equipment necessary
No multidisciplinary approach required
No need for complex and fine maneuvers
We can move on to brain - thorax - extremities
immediately
Damage control of extremities trauma
• Stable patient –
osteosynthesis
• Polytrauma patientExternal fixation
• Do not insist on
anatomical reposition,
but on fracture
stabilisation
• Open fracturedebridment
• Timing is individual
considering clinical state
Dedicated trauma surgery courses
Dedicated trauma fellowships
• Brigham and Women’s Hospital, Boston, USA
• Sunnybrook Health Sciences Centre, University of
Toronto, Canada
• Universidad del Valle, Colombia
• The Johns Hopkins University, Baltimore, USA
• University of Pittsburgh, USA
• University of Nevada School of Medicine, USA
• Wake Forest University Baptist Medical Center, USA
• Liverpool Hospital, Sydney, Australia
• Canberra Hospital, Canberra, Australia
Summary
• Any setting can become problematic for the
practicing surgeon
• Beforehand planning for MCI’s is advised
• The knowledge of damage control techniques
is life saving in both trauma and non-trauma
cases
• Damage control surgery is possible with a
minimum technical armamentarium
• Surgical trauma training is widely available
Thank you for your
attention