Learning from General Surgical Cases

Background

A female patient in her mid-40s underwent a gastric sleeve resection, during which a large hiatal hernia was discovered. The surgeon opted to reduce the hernia at the same time.

During the procedure, a perforation of the oesophagus occurred. Repair was unsuccessful and leaks were noted. A gastroenterologist was called to perform an EGD and stent placement.

Post-operatively, the patient continued to have complications and was returned to the operating theatre nine times in an attempt to repair the leak (stents were too small in diameter, then not long enough, then migrated into the peritoneum via the oesophageal perforation).

Infection, then sepsis developed, and the patient endured a difficult journey of recovery.

Learning points

This case highlights several learning points for consideration.

Consent

The patient was consented for a sleeve gastrectomy. However, on discovering a large hiatal hernia the surgeon opted to reduce it, even though the patient had not consented for this additional procedure. Unfortunately, a perforation occurred which required further surgery. While perforation is a known complication of hernia repair, consent for this procedure was not obtained.

This case also highlighted a failure of the surgeon to properly manage the patient’s expectations (specifically with regard to subsequent surgeries).

Lessons:

There is an emerging consensus to look for a hiatal hernia at the time of sleeve gastrectomy surgery and repair it if present. A clinician should not perform additional surgery (that the patient has not been consented for) while the patient is undergoing a scheduled procedure unless an emergency situation arises that is life-threatening.

In this instance it would have been prudent for the surgeon to have discussed the possibility of a hiatal hernia and consent the patient for this surgery, should a concurrent hiatal hernia repair be required.

The GMC state in para 31 of Decision making and consent:

“You must be clear about the scope of decisions so that patients understand exactly what they are consenting to. You must not exceed the scope of a patient’s consent, except in an emergency.”

Inadequate informed consent is commonly identified as a contributory factor in a patient’s dissatisfaction with the care provided, which ultimately has the potential to lead to litigation. Please refer to GMC guidance, Decision making and consent.

A meaningful consent discussion, ascertaining from a patient what a ‘good outcome’ would be if the procedure took place, can help clinicians determine whether a patient’s expectations are realistic or clinically achievable.

Technical skill/Procedural complications

In this instance, there was a complication in reducing the hernia. Complications following surgery may be the result of procedural error, or failure to timely recognise and/or monitor/manage issues. Cases involving the management of surgical patients, at all stages of the surgical journey, are frequently related to a surgeon’s response to developing complications.

Lessons:

Ongoing evaluation of procedural skills and competency is essential. Surgeons should engage in performance improvement opportunities to maintain and develop their technical skills.

Suboptimal technical skills such as poor surgical technique is often a contributory factor in clinical negligence claims. In addition, non-technical skills such as the absence of shared decision-making and/or poor communication that results in a lack of informed consent are all contributory factors in cases of adverse surgical outcomes.

Clinical judgement in this case

The surgeon made the decision to operate on the hernia, whilst he was performing the sleeve gastrectomy. Additionally, there was also concern regarding the surgeons’ clinical decision-making regarding the preparedness of the patient for the subsequent surgeries.

Lessons:

A review of PMP cases notified over a six-year period, by consultants working in independent practice, identified a significant number of cases related to general surgery. In 83% of these cases, the surgeon’s clinical judgement was identified as a contributing risk factor, which impacted patient outcomes.

A surgeon’s clinical judgement is informed by:

• information gathered from the patient.
• observation.
• the practitioner’s own personal experience, knowledge, practice, and critical-thinking skills.

Because clinical judgement is a complex process involving various cognitive functions, it’s easy to understand why it is frequently a key factor in clinical negligence allegations. The prevalence of clinical judgement issues is almost certainly linked with their complexity and the fact that they tend to be less amenable to ‘straightforward fixes’ than other contributing factors, such as system failures.

The complex nature of clinical reasoning and decision-making makes it vulnerable to various cognitive errors, including knowledge deficits, faulty heuristics (these are useful mental shortcuts and rules of thumb that provide a best-guess solution to a problem) and affective biases/influences. These errors can subconsciously lead to lapses in judgement, which in turn can result in decision-making and technical mistakes.

In summary

Doctors must respect and understand that, in a non-emergency setting, a patient’s consent is essential before any medical/surgical treatment or examination is performed.

A clinician should not perform additional surgery while performing a scheduled procedure unless an emergency situation arises that is life-threatening.

Finally, it is essential, following an adverse outcome, to investigate, explain and apologise to the patient. Please refer to the GMC’s Openness and honesty when things go wrong: The professional duty of candour.

If you have any queries or concerns surrounding the issues raised in this case study, please do not hesitate to call the PMP medicolegal helpline. The helpline is open 24/7, and contact details can be found in your policy documents.