Any veterinarian performing surgery is bound to encounter a case that did not go as planned. Whether the patient had a complication, a true error was made, or the client's perception of their pet's outcome was skewed, these cases can take a toll on all veterinary staff members involved. Although these cases can feel defeating, they often present learning opportunities.
A recent study from the British Journal of Surgery identified 16.8 percent of human patients undergoing a surgical procedure suffer at least one complication. Most of these errors tend to be minor and not require intervention; however, approximately five percent of human patients in this study suffered permanent disability or mortality.1
Pre- and post-surgical checklists have been shown to minimize operating room complications, but they can be challenging to implement in practice. Taking appropriate precautions, having a team-based approach, and clear communication at each step can help improve results. Below are some common roadblocks to a successful surgical outcome.
Communication
Thorough, well-documented conversations with clients before and after a surgical procedure can help minimize any misunderstandings regarding a surgical process. Prior to any scheduled surgical procedure, a complete examination and in-person consultation with the client should be performed. This provides an opportunity to discuss the patient's history, describe the surgical procedure and review the goals, expected outcome and potential complications of the surgery. This also helps ensure the client is aware of all the reasonable treatment options available for the condition, and the pros and cons of each option.
For example, with a cranial cruciate ligament injury tibia plateau leveling osteotomies or tibia tuberosity advancement procedures are the gold standard recommendation. However, if these advancement procedures are not available at your hospital, the client needs to be made aware of these techniques and the option for referral before committing to extracapsular stabilization.
Although it would be impossible to discuss every possible complication, it is critical the most common potential complications are discussed with the client. Knowledge of the procedure and possible complications are important to review with the client to help them make an educated decision. This is especially important if the patient has concurrent abnormalities that make a complication more likely.
Additionally, laying the groundwork for what to expect the day of surgery is also important–will the pet be released from the hospital the same day? Will a bandage be present? Will the client need to have medications filled at an outside pharmacy?
Finally, the pre-surgical consultation allows the client to ask questions and ensure they understand their role in appropriate after care of their pet. Client handouts can be helpful to reinforce what was discussed at the consultation and allow the client to review the information after the appointment when they may feel more relaxed.
Communication about the procedure day can make the client's experience of the entire process better. Knowing what to expect at the time of drop off, when communication from the veterinary team will occur (i.e. before the procedure starts, when surgery is complete, etc.) can go a long way.
If the client knows what to expect as far as a timeline on the day of the procedure, it will hopefully limit the number of phone calls from the client inquiring about their pet's progress. At the time of discharge, written instructions for aftercare should be reviewed with a knowledgeable team member. This will give the client an opportunity to have their questions answered and a written document to reference once they are at home with their pet.
Information regarding timing of postoperative medications, bandage or incision care, and ways to troubleshoot minor issues (e.g. constipation, etc.) can be helpful for clients to have. A copy of this information should be kept in the pet's record so any team member tasked with follow-up client communication knows what was provided to the client.
Incorrect or incomplete diagnosis
This error often occurs with incomplete pre-operative diagnostics, lack of a thorough exam, or failure to recognize concurrent disease. Poorly positioned radiographs may fail to identify a fracture. This is especially important with young puppies and kittens where the presence of growth plates can complicate interpretation of an image.
Focusing on the presenting complaint without a complete exam can lead to tunnel vision. Consider the following example: a middle-age toy breed dog presents for hind limb lameness and is diagnosed with medial patella luxation. Since this is considered a developmental orthopedic condition, the patella luxation is not a new problem for this patient. It is possible osteoarthritis has developed and is leading to discomfort. However, concurrent cranial cruciate ligament injury is present in 41 percent of these patients and should be looked for on exam.2
In some patients, systemic disease may slow healing more than expected cause failure to heal or lead to developing a similar condition in another limb in the future. For example, a dog headed to the operative room for removal of an intestinal foreign body that is found to be hypotensive on a pre-operative exam should have reasonable attempts made to correct the hypotension prior to surgery. Since hypotension is a risk factor for dehiscence,3 the patient also needs close monitoring of blood pressure during the procedure with a plan in place for treatment if it develops peri or postoperatively.
Another example is patients treated for common calcaneal tendon avulsion should always be evaluated for concurrent endocrine disease (hyperadrenocorticism and hypothyroidism). These diseases may need to be treated to limit the chance of a similar condition developing in the other hind limb.4
Incomplete diagnostics
Some of the most common errors made in the operating room are due to inadequate planning prior to the procedure. Thorough, appropriate pre-operative diagnostics can limit this type of mistake. Prior to any major procedure, recent blood work evaluating major organ function is invaluable. This can help guide the need for additional diagnostics as well as selection of pre-anesthetic and postprocedural medications.
Thorough diagnostic imaging is necessary to evaluate for comorbidities and surgical planning. Thoracic radiographs can aid in evaluation of metastatic disease, pneumonia, cardiac enlargement, and lower airway inflammation. If a patient has sustained a femur fracture from motor vehicle trauma, imaging is necessary to look for concurrent injuries such as pulmonary contusions, hernias, and urinary bladder rupture.
Equally important to pre-operative diagnostics are post-operative diagnostics. Following a fracture, repair radiographs need to be taken to document appropriate reduction of the fracture and placement of the implants. Post-operative radiographs after a femoral head ostectomy need to document complete removal of the femoral head and neck. If radiopaque urinary calculi are removed via cystotomy, radiographs are needed after surgery to confirm removal of all stones.
Residual calculi were present in 20 percent of patients on post-operative imaging, according to a case study.5 If a surgical error is noted on post-procedure imaging, the patient should be taken back to the operative room to replace the implants, re-attempt fracture reduction or remove residual bladder stones.
As veterinarians performing surgery, mistakes are inevitable at some point. Sometimes the mistake is a miscommunication with the client. Sometimes the mistake will be not completing diagnostics prior to the procedure. Other times the mistake will be a true technical error made in the operating room. However, it is important to learn the painful lessons and grow our skills with any mistakes. Communicating with clients before, during, and after a procedure, as well as completing appropriate diagnostics to help make the correct diagnosis, can limit many complications in a surgical patient.
Kendra Freeman, DVM, MS, DACVS, is a graduate of Colorado State University and maintains dual certification with the American College of Veterinary Surgeons. Dr. Freeman is an associate surgeon in Albuquerque, N.M. Her case load consists of orthopedics, general soft tissue, and sports medicine cases with the occasional return to her roots in large animal lameness and surgery.
References
- Bosma E, Veen EJ, Roukema JA. Incidence, nature and impact of error in surgery. Br J Surg. 2011 Nov;98(11):1654-9. https://pubmed.ncbi.nlm.nih.gov/21706475
- Campbell CA, Horstman CL, Mason DR, Evans RB. Severity of patellar luxation and frequency of concomitant cranial cruciate ligament rupture in dogs: 162 cases (2004-2007). J Am Vet Med Assoc. 2010 Apr 15;236(8):887-91. https://pubmed.ncbi.nlm.nih.gov/20392187
- Grimes JA, Schmiedt CW, Cornell KK, Radlinksy MA. Identification of risk factors for septic peritonitis and failure to survive following gastrointestinal surgery in dogs. J Am Vet Med Assoc. 2011 Feb 15;238(4):486-94. https://pubmed.ncbi.nlm.nih.gov/21320019
- Piermattei DL, Flo GL, DeCamp CE. Handbook of Small Animal Orthopedics and Fracture Repair, 4th ed. St Louis: Saunders Elsevier, 2006:674–678. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034428
- Grant DC, Harper TA, Werre SR. Frequency of incomplete urolith removal, complications, and diagnostic imaging following cystotomy for removal of uroliths from the lower urinary tract in dogs: 128 cases (1994-2006). J Am Vet Med Assoc. 2010 Apr 1;236(7):763-6. https://pubmed.ncbi.nlm.nih.gov/20367043
