Deviation from a preoperative surgical and anaesthetic care plan is associated with increased risk of adverse intraoperative events in major abdominal surgery

A Narrative Review on Intraoperative Adverse Events: Risks, Prevention, and Mitigation

INTRODUCTION

Adverse events from surgical interventions are common. They can occur at various stages of surgical care, and they carry a heavy burden on the different parties involved. While extensive research and efforts have been made to better understand the etiologies of postoperative complications, more research on intraoperative adverse events (iAEs) remains to be done.

METHODS

In this article, we reviewed the literature looking at iAEs to discuss their risk factors, their implications on surgical care, and the current efforts to mitigate and manage them.

RESULTS

Risk factors for iAEs are diverse and are dictated by patient-related risk factors, the nature and complexity of the procedures, the surgeon's experience, and the work environment of the operating room. The implications of iAEs vary according to their severity and include increased rates of 30-day postoperative morbidity and mortality, increased length of hospital stay and readmission, increased care cost, and a second victim emotional toll on the operating surgeon.

CONCLUSIONS

While transparent reporting of iAEs remains a challenge, many efforts are using new measures not only to report iAEs but also to provide better surveillance, prevention, and mitigation strategies to reduce their overall adverse impact.

Paradigm shift: should preoperative 3D reconstruction models become mandatory before hepatectomy for hepatocellular carcinoma (HCC)? Results of a multicenter prospective trial

BACKGROUND

A preoperative surgical strategy before hepatectomy for hepatocellular carcinoma is fundamental to minimize postoperative morbidity and mortality and to reach the best oncologic outcomes. Preoperative 3D reconstruction models may help to better choose the type of procedure to perform and possibly change the initially established plan based on conventional 2D imaging.

METHODS

A non-randomized multicenter prospective trial with 136 patients presenting with a resectable hepatocellular carcinoma who underwent open or minimally invasive liver resection. Measurement was based on the modification rate analysis between conventional 2D imaging (named "Plan A") and 3D model analysis ("Plan B"), and from Plan B to the final procedure performed (named "Plan C").

RESULTS

The modification rate from Plan B to Plan C (18%) was less frequent than the modification from Plan A to Plan B (35%) (OR = 0.32 [0.15; 0.64]). Concerning secondary objectives, resection margins were underestimated in Plan B as compared to Plan C (-3.10 mm [-5.04; -1.15]).

CONCLUSION

Preoperative 3D imaging is associated with a better prediction of the performed surgical procedure for liver resections in HCC, as compared to classical 2D imaging.

Management of Tracheoesophageal Fistula Repair With Cardiac Dextroposition and Right Lung Agenesis: A Case Report

Tracheoesophageal fistulae (TEF) commonly occur as part of the vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal, and limb abnormalities (VACTERL) association. However, pulmonary agenesis is not typically seen with TEF. We report the anesthetic management of a TEF repair in a 33-week-old, 1.6-kg, monochorionic diamniotic twin with right lung agenesis, intrauterine growth restriction, and cardiac dextroposition. Due to the unique position of the heart, the patient periodically lost complete cardiac output during the exposure and repair of the esophagus.

Introducing a new collaborative prenatal clinic model

OBJECTIVE

To measure quality of care-planning for women in a new collaborative prenatal model of care.

METHODS

A collaborative patient-centered (CPC) model was introduced into a tertiary prenatal clinic, replacing the traditional model. A retrospective analysis was conducted of women with a first documented hospital doctor contact between February 1, 2015, and October 1, 2016. Quality of care-planning before and after introduction of the model was compared by measuring the number and size of documented care plans and amount of doctor contact. Categorical data were compared using χ² or Fisher exact tests; continuous data were analyzed using the student t test.

RESULTS

Quality of care was measured for 3606 women before, and 3511 after, introduction of the CPC model. Under the model, more women had clinical risks identified and care plans documented (2224 [63.3%] vs 1883 [52.2%]; P<0.001), and more clinical risks were identified (1.07 vs 0.74; P<0.001). Doctors documented more in each care plan (P<0.001) and had more subsequent clinical contact with women (0.69 ± 1.23 vs 0.88 ± 1.34; P<0.001) in the model.

CONCLUSION

Introduction of a collaborative model in a tertiary prenatal clinic improved identification of clinical risks and documentation of care plans, and increased doctor contacts.

Preoperative detection of intrahepatic venovenous shunt treated by microwave precoagulation during right hepatectomy

A 53-year-old woman underwent a 2-stage right hepatectomy for bilobar metastasis of an ileal neuroendocrine carcinoma. Preoperative three-dimensional computed tomography reconstruction helped to diagnose an intrahepatic venovenous shunts from the right and middle hepatic veins to the left hepatic vein, which could cause a intraoperative bleeding. Hemostasis was performed by means of precoagulation with microwave-assisted coagulation.

Systematic review of the use of pre-operative simulation and navigation for hepatectomy: current status and future perspectives

Pre-operative simulation using three-dimensional (3D) reconstructions have been suggested to enhance surgical planning of hepatectomy. Evidence on its benefits for hepatectomy patients remains limited. This systematic review examined the use and impact of pre-operative simulation and intraoperative navigation on hepatectomy outcomes. A systematical searched electronic databases for studies reporting on the use and results of simulation and navigation for hepatectomy was performed. The primary outcome was change in operative plan based on simulation. Secondary outcomes included operating time (min), estimated blood loss, surgical margins, 30-day postoperative morbidity and mortality, and study-specific outcomes. From 222 citations, we included 11 studies including 497 patients. All were observational cohort studies. No study compared hepatectomy with and without simulation. All studies performed 3D reconstruction and segmentation, most commonly with volumetrics measurements. In six studies reporting intraoperative navigation, five relied on ultrasound, and one on a resection map. Of two studies reporting on it, the resection line was changed intraoperatively in one third of patients, based on simulation. Virtually predicted liver volumes (Pearson correlation r = 0.917 to 0.995) and surgical margins (r = 0.84 to 0.967) correlated highly with actual ones in eight studies. Heterogeneity of the included studies precluded meta-analysis. Pre-operative simulation seems accurate in measuring volumetrics and surgical margins. Current studies lack intraoperative transposition of simulation for direct navigation. Simulation appears useful planning of hepatectomies, but further work is warranted focusing on the development of improved tools and appraisal of their clinical impact compared to traditional resection.

Towards cybernetic surgery: robotic and augmented reality-assisted liver segmentectomy

BACKGROUND

Augmented reality (AR) in surgery consists in the fusion of synthetic computer-generated images (3D virtual model) obtained from medical imaging preoperative workup and real-time patient images in order to visualize unapparent anatomical details. The 3D model could be used for a preoperative planning of the procedure. The potential of AR navigation as a tool to improve safety of the surgical dissection is outlined for robotic hepatectomy.

MATERIALS AND METHODS

Three patients underwent a fully robotic and AR-assisted hepatic segmentectomy. The 3D virtual anatomical model was obtained using a thoracoabdominal CT scan with a customary software (VR-RENDER®, IRCAD). The model was then processed using a VR-RENDER® plug-in application, the Virtual Surgical Planning (VSP®, IRCAD), to delineate surgical resection planes including the elective ligature of vascular structures. Deformations associated with pneumoperitoneum were also simulated. The virtual model was superimposed to the operative field. A computer scientist manually registered virtual and real images using a video mixer (MX 70; Panasonic, Secaucus, NJ) in real time.

RESULTS

Two totally robotic AR segmentectomy V and one segmentectomy VI were performed. AR allowed for the precise and safe recognition of all major vascular structures during the procedure. Total time required to obtain AR was 8 min (range 6-10 min). Each registration (alignment of the vascular anatomy) required a few seconds. Hepatic pedicle clamping was never performed. At the end of the procedure, the remnant liver was correctly vascularized. Resection margins were negative in all cases. The postoperative period was uneventful without perioperative transfusion.

CONCLUSIONS

AR is a valuable navigation tool which may enhance the ability to achieve safe surgical resection during robotic hepatectomy.