Complications: What They Do to the Surgeon

28 Complications: What They Do to the Surgeon

David Warwick

Abstract

The effect that a complication has on a patient is obvious: extra pain, extra suffering, extra anxiety, and extra treatment. But a complication can, indeed should, affect the surgeon. That effect can be positive—a humbling learning experience—but it may be very negative with so much anxiety and rumination that the surgeon becomes the “second victim.” No surgeon can avoid all complications but all surgeons can avoid some complications. When a complication happens, the surgeon should always feel responsible and own the problem. The surgeon should manage not only the complication and the patient’s emotions, but also their own emotions. This is not easy but can be summarized as honest reflection in a supportive environment.

Keywords: complications, error, negligence, resilience, surgeon, coping, resilience

28.1 Introduction

Every surgeon has complications. If a surgeon says he never has a complication then he must be Delinquent (never operating), Deceitful (lying to others), Deluded (lying to himself) or Daft (too stupid to realize).

Every surgeon carries within himself a small cemetery, where from time to time he goes to pray—a place of bitterness and regret, where he must look for an explanation for his failures.

René Leriche, La Philosophie de la Chirurgie, 1951

In this chapter, we will examine complications—how they can be avoided, how they can affect the surgeon, how litigation can be avoided; we will look at strategies to help the surgeon cope and avoid becoming the second victim.1

28.2 Complications and Errors

28.2.1 What Is a Complication?

Not all negative outcomes are complications. Dindo defined negative outcomes as complications, sequelae, and failure to cure.² A complication would be a deviation from the normal postoperative course whereas a sequela would be an expected consequence (stiffness after a metacarpophalangeal [MCP] fusion, weak pinch after a trapeziectomy) and failure to cure would be when the original purpose of the operation is not achieved (residual flexion contracture after fasciectomy, residual tumor after excision biopsy, persisting nonunion after bone graft).

28.2.2 The Chance of a Complication

Why Is the Risk Important?

If we know the chance of a complication, then we can do two important things:

●Warn the patient by fully informed consent.

●Take all measures to reduce that risk.

Do not Trust the Literature

The chance of a complication occurring is more of a guess than a fact. We have some idea from the journals and textbooks but these publications are subject to ascertainment bias (does a surgeon always admit to every complication, let alone publish their high rate?) and publication bias (do Journals want to publish bad results?). Also, even if the complication rate seems low, remember that in a small series a confidence interval will reveal a potentially much higher risk.

Audit Your Work

A surgeon should monitor the outcome of their work—this should include a system to collect the complications that occur. Various electronic systems are available. It takes some effort and some integrity to record each and every complication, but the data which are collected will inform the surgeon how to improve their practice and will inform the patient of the risk they are taking with their own choice of surgeon.

28.2.3 When Is a Complication a Non-negligent Error and When Is It Negligence?

It is important to distinguish between a complication, an error, and negligence. An error can cause a complication, but not all complications are caused by an error. And not all errors are negligent. The patient, the surgeon, and indeed the lawyer should understand the distinction.

Some complications just happen—an unavoidable deviation from the expected outcome caused by a natural event, such as infection, complex regional pain syndrome (CRPS), failure of a bone to heal, a tender carpal tunnel scar, and extensor pollicis longus (EPL) rupture after Colles fracture. Some complications reflect risks which occur in a proportion of patients however well the surgery is performed, such as an unstable Sauve-Kapandji, midcarpal arthritis after scaphotrapeziotrapezoid (STT) excision, and nonunion of scaphoid fixation.

Some complications occur as a result of understandable and forgivable (non-negligent) surgical error: dividing a nerve in complex revision Dupuytren surgery, a screw not quite perfectly placed in a comminuted fracture, a wound closure after a fasciotomy which is too tight, a broken drill tip, a K-wire impinging the lateral band causing proximal interphalangeal (PIP) stiffness.

Some complications are negligent and reflect poor decision making: an unstable silastic implant in the index finger PIP, a failed wrist replacement in a young heavy worker.

Some complications are negligent and reflect poor surgical technique: a distal radius screw penetrating the joint, damage to the median nerve during carpal tunnel release, CRPS after careless damage to a cutaneous nerve, failure to use X-rays for procedures involving metal.

Some complications are negligent and poor practice: wrong-site surgery, thrombosis or infection when prophylaxis is not used according to guidelines, failure to check imaging prior to surgery, inadequate postoperative splinting.

Some complications are caused by the surgeon’s team but beyond the surgeon’s control: infection caused by someone else’s poor aseptic discipline in theater or clinic, inadequate anesthesia causing the patient to move, incorrect physiotherapy.

Some complications are the patient’s fault: scaphoid nonunion in a patient who still smokes, infection in a patient who removes their own dressing, malunion in a patient who removes their own plaster or wires too soon.

28.3 Avoiding Complications and Consequences

28.3.1 The Competence of a Surgeon

A competent surgeon is not just defined by the technical skill of the operation itself but by the skill of preoperative decision making and consent, as well as the skill with which postoperative complications are managed. The latter skill needs not only technical expertise for the physical treatment but especially psychological expertise for essential emotional treatment.

28.3.2 How Can a Surgeon Avoid Complications?

No surgeon can avoid all complications but all surgeons can avoid some complications. When a complication happens, the surgeon should always feel responsible and usually feels unhappy. Therefore, for a surgeon to cope with a complication, they must be comfortable that they have done everything possible to avoid that complication.

●Choose the most suitable procedure for each individual patient—a gymnast will hate a fused thumb carpometacarpal (CMC) whereas a road digger will hate an unstable trapeziectomy.

●Choose an operation for which you are trained and with which you are experienced—surgeons do operations better when they do lots of them.

●Avoid experimentation—it takes many procedures by many surgeons in many centers before the technique is considered reliable and before the potential flaws are known. Patients are not laboratory rats.

●Understand the potential complications for each procedure and do what you can to avoid them—put the volar plate proximal to the watershed line to avoid tendon rupture, minimal resection of the distal pole of the scaphoid for STT osteoarthritis (OA).

●Use operating loupes—avoid damaging nerves and vessels.

●Operate meticulously—place tendon sutures perfectly, close the wound impeccably, check each screw length twice.

●Plan postoperative care carefully—ensure the therapist will see the PIP replacement within just a few days to avoid stiffness, do not change dressings too early which invites infection, apply the correct splint at the correct time.

●Follow established guidelines—WHO Checklist, handwashing, “bare below the elbows.”

●Use evidence-based medicine not your own opinion—thromboprophylaxis and antibiotic prophylaxis should not be used on all patients but only when recommended.

●Warn patients not to smoke (they usually ignore this).

●Ensure diabetes and anticoagulation are controlled.

28.3.3 Consent

Consent Is Essential to Manage Complications

If the patient experiences an unavoidable complication—an unfortunate but recognized natural event—then they will share the surgeon’s despair and disappointment but only if they realize that it was a risk that they had been prepared to take. This is why thorough preoperative consent is so important. If a complication occurs after surgery, then a properly consented patient will think the surgeon is wise for having warned them and will work with the surgeon as their partner in sorting it out; a patient who was not consented properly may see the surgeon as incompetent.

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