What Went Wrong?
Preventing surgical complications is a top priority for health care in the U.S.
Chances are good you’ve had an operation at some point in your life — and that you may have suffered a complication. More than 51 million inpatient operations are performed in the United States every year, and according to Vicky Woodruff, PhD, up to 12 million non-cardiac operations involve complications of some kind. (Cardiac operations are studied separately.) Some postoperative mishaps are minor and short-lived, but others are deadly; many are entirely avoidable.
That’s why preventing them is so important, says Woodruff, a physiologist in The University of Texas Health Science Center at Houston (UTHealth) Medical School’s Division of General Surgery who studies complications prevention. “We’re not only aware of what’s going on,” she says. “We’re trying to blaze the trail of reducing postoperative complications.”
It’s a complex challenge. There are so many types of postoperative complications, and they don’t arise from just one cause. Common ones include pain, fever, excessive bleeding, fluid buildup and minor lung collapse (atelectasis) due to not breathing deeply. Wounds can open up or get infected, the bowels and bladder can stall, or the patient can suffer sepsis, a blood clot in the lungs, heart attack or stroke. Infections are especially common in patients with diabetes. Bleeding is more likely in patients taking blood thinners like warfarin; there are a number of supplements on the market that also can thin the blood.
General anesthesia, too, can carry risks. Vomiting, damage to teeth or vocal cords, allergy to the anesthetic, or a compressed nerve are all possibilities, as well as more serious problems like cardiovascular collapse or brain damage. And every operation has its own hazards, such as nicking the bile duct during gallbladder surgery.
Planning the approach
With planning, preventing these problems starts long before the operation itself. The preoperative evaluation involves examining the patient and reviewing his or her medical record. This helps the anesthesiologist choose the safest form of anesthesia for the patient’s operation.
Meanwhile, the surgical team must decide on the best approach, since some operations can be done a number of ways. For example, for a gallbladder operation, a surgeon can choose a large incision or a minimally invasive option such as laparoscopy, depending on a patient’s unique circumstances.
In laparoscopy, slender instruments and lights are inserted into small poke-holes through tubes. Many of these operations can be done through a single incision. Some bariatric procedures can even use an incision-free “endoluminal” approach, in which surgical instruments enter through a body cavity like the mouth. Minimally invasive procedures are often preferred: they greatly reduce the risk of pain or an infected incision.
Robotic surgery is another approach. It’s a type of minimally invasive surgery requiring additional training. As one of the largest robotic-surgery training centers in the country, UTHealth has over a decade of experience with this option. Surgeons here employ it in bariatric, gynecologic, oncologic and urologic procedures.
Like laparoscopy, robotic surgery is done through small incisions and tubes through which slender robotic arms and a high-definition camera are inserted. To control the robot, the surgeon sits at a console; this technique allows for great steadiness and precision.
“Robotic surgery takes several of the stresses on the surgeon away,” Woodruff says. “The robot doesn’t get fatigued. The robot can hold something forever and it doesn’t jiggle — and it can perform much more minute movements than a human can.”
Pain is an important complication after surgery. If it’s uncontrolled, it raises the risk of other complications. It kicks up blood pressure and heart rate, which further stresses the body. A patient in pain may breathe shallowly and cough less, raising the risk of partial lung collapse or pneumonia. Similarly, pain can make it harder to move around, and that’s a problem in itself. The human body doesn’t react well to lying immobile for days. Bed rest can lead to muscle wasting, slower blood flow, bowels that don’t want to move and lungs that don’t fully expand. (Unfortunately, opioid medications can make matters worse by causing drowsiness.) On top of everything else, a patient in pain often becomes anxious, frightened or sleepless.
On the other hand, getting postoperative pain under control gets patients out of bed quicker and home sooner — and leaves them feeling far better about their surgical experience.
Medical teams attack pain on a number of fronts, tailoring their approaches to the patient. Beginning pain management with local anesthesia or IV pain medications as the surgery is winding up can help. So can patient-controlled pain pumps. So do epidural injections, local anesthesia or nerve blocks that relieve pain in, say, just one hand or leg. Woodruff, Kulvinder Bajwa, MD, and their fellow UTHealth researchers are also studying new non-opioid pain medications that don’t cause drowsiness.
Use of safety checklists
What goes on before and after surgery is, perhaps, overshadowed by what goes on during it. Like the cockpit of a passenger jet, the operating room is a place where lives are at stake, a team is in charge and details matter. Rather than relying on memory or quick observation, pilots go through a preflight checklist, forcing themselves to think about each safety-related step so that nothing is overlooked. Many an air disaster has been prevented that way.
Operating room personnel, including those UTHealth surgeons, have borrowed that lifesaving approach from aviation. The World Health Organization’s 19-point surgical safety checklist for operating rooms asks the operating-room staff to take three timeouts: one before anesthesia, one before the skin incision and one before the patient leaves the operating room.
The first timeout checks simple things like the name of the patient, the intended operation and body site, and whether the anesthesia machine is working. The second timeout comes just before the surgeon makes the first incision: Everyone in the operating room introduces themselves and explains their role; the patient’s identity and surgical plan are re-verified, and surgeon, anesthesia personnel and nurses go over potential problems. Before the patient leaves the OR, the team takes a third and final timeout to discuss postoperative management and verify that no foreign bodies were inadvertently left inside the patient.
“If you’re flying an airplane, you go through the same checklist every single time,” says Richard Andrassy, MD, who is a retired Air Force pilot and a surgeon with 42 years of experience. Similarly, in the operating room, everyone participates in the timeout checklists. “Even if, in 20 years, one patient is protected from an error, then that’s pretty good if you’re the one patient,” he says.
Smooth teamwork, too, is crucial for reducing complications. That’s one of the reasons all the OR personnel introduce themselves.
“If everybody’s afraid of you, then no one’s going to speak up if something’s going wrong,” Andrassy says. “I try to make the operating room a place where everybody feels like they’re part of the team.”
How you can help
If you’re heading for surgery yourself, what can you do to help prevent postoperative complications? Quite a bit, actually.
First, quit smoking. Smoking raises the risk of death from surgery. It causes inflammation throughout the body that can interfere with recovery.
Next, get in shape. You wouldn’t start up a mountain without some practice hikes, yet an operation can be just as stressful. So getting fit and optimizing your weight can help your body meet energy demands both during the operation and the recovery period.
Andrassy recalls preparing for his own total knee replacement by going to physical therapy and losing weight. Patients who don’t prepare may take many weeks to recover. But Andrassy went home two days after surgery and returned to his own surgical duties in a week.
Woodruff and others at UTHealth are among the first researchers in the United States to study the patient’s entire physiologic system to see if it can withstand the energy demands of the post-surgical period. This testing is done before non-emergency surgery and looks for predictors that may tell them what the patient’s risk is of having a post-op complication. According to Woodruff, for patients at high risk of having a complication, a six-week aerobic program prior to surgery plus a close look at the patient’s nutritional status and vitamin levels may eventually reduce or eliminate most postoperative complications altogether.
“Whenever a whole system is put under stress, wherever that weak link point is, that’s probably more likely where it’s going to break down,” Woodruff says.
What you do after surgery matters, too. Once the surgeon deems it’s safe to get out of bed afterward, do so. Moving around wakes up the bowels and bladder and helps prevent muscle wasting and dangerous blood clots. Postoperative patients should also work hard to breathe deeply and get moving in accordance with the surgeon’s instructions, even if it takes extra pain medication to get there.
During recovery, follow instructions, Woodruff adds. That includes taking medications as prescribed even if you feel fine, diligently wearing support stockings and letting the surgeon know if you suspect that something is wrong. For example, if you are supposed to be wearing pressure stockings and they aren’t on, put them on or ask for help doing it. If you’re confused about your medication, ask a question. Patients have a lot of power over their own recovery.
“It’s got to be a team approach between the patient and the doctor,” Andrassy says.
An operating room steeped in safety culture, patients who are a proactive part of their own care team, and an experienced and detail-oriented team are all powerful defenses against surgical complications.
But even if everyone does everything right, Andrassy says, complications can and do occur. So the aim is to limit the preventable complications that arise from human error or neglect.
“Being born is a terminal illness,” Andrassy quips. “But we can limit the number of complications that we cause — by paying attention to details.”