ERRORS AND

COMPLICATIONS IN

VETERINARY

SURGERY

DVM MARIA ELENA MARTINEZ

BUENOS AIRES, ARGENTINA "Every failure teaches a man

something, if he will learn" Charles

Dickens

2

Necropsy

Feline with peritonitis

because of a linear foreign with a body

postoperative dehiscence of the intestinal

suture, septic peritonitis was observed

Complication:adverse event related to the surgical procedure, deviating from the desired course and may be associated with regular or bad outcomes

• worsening of signology• development of new symptoms

• new pathologies involving other organs• may appear in the pre, intra and post-surgical

stage

PhlegmonBernese mountain dog, 8 years old: with cervical pain, no motor deficit. Under treatment with corticosteroids and physical rehabilitation during a month of evolutionWith a partial response and even advancing towards a tetraparesis. Decompression surgery is decided, but begins an image of decay, hyperthermia, anorexia and fluctuating deformation in the right forelimb

Surgical drainage is performed,

sampling for cultivation/antibiogram

washed with saline solution

Penrose+ bandage drainage

daily changes+

Antibiotics

It recovers satisfactorily and

decompressive surgery is performed

cervical

Complication

WHAT’S AN

ERROR?

is the inappropriate conduct of the

professional for improbability,

recklessness or negligence that causes harm to

the patient's lifenot all

complications are caused by errors

Human error

Inadequate or incorrect

information

Correct information but

incorrect applied

methodologyCorrect

information and methodology but

execution is imperfect

8

Errors are due to:human conditionprofessional status

Detailed and

complete

medical

record

Mistakes can start as soonas you start taking the firststeps towards a diagnosis

Lack of foresight

Lack of knowledge

Lack of resources

Lack of skills

Lack of time

Poor comunication within theteam

Making themistake: demonstratesprofessionalweaknessesand involvesthe possibilityof CAUSING HARM

Confessingthe error isthe way

10

Don'tconfess from

guiltConfess fromresponsibility

TAKE AN ERROR AS A SOURCE OF POSITIVE FEEDBACK

12

error

retrospectiveplanting

careeradvancement and

improvement

change in attitude

MEASURES TO TAKE WHEN THE ERROR IS IDENTIFIED (WEARS,1999)

emphasize more in the system than

in people

non-punitive approach

determine multifactorial

nature

estimate what mistakes can be

made

develop a culture of safety

14

Hide Live with

Search for culprits

Avoiding responsibility and blaming others

Facing error

Asking for forgiveness and compensating and learning

from

• we are the only one responsible for who we want to be

• Facing one's own mistakes is the key

to never commit them again

• Acknowledging the error is an act of

• RESPONSIBILITY, not to recognize

• and hiding it is much more serious than the mistake itself

IATROGENIA

medical error

misdiagnosis

medical negligence/inappropriate procedure

error in recipe or indecipherable prescription

drug interaction/side effects or adverse effects

intra-hospital infection

It is a patient's injury caused by doctors, medication or

therapeutic treatment within the precise indication. It's always unintentional,

causing a complication in the treatment.

It depends o

n th

e case

……

IATROGENIA IS NOT MAL PRAXIS

17

LACK OF

ABILITY

IMPRUDENCE NEGLIGENCE

MAL PRAXIS FORTUITOUS

CASE

“Loose sponge"

something forgotten inside the patient

ERROR

• Had GDV surgery 8 months ago

• patient had a gastropexy

• After surgery: recurrent dilations

• Lost 10 kg of body weight: 45 kg to 35 kg

• Changed DVM: Endoscopy and indicated symptomatic treatment

• with cisapride 0.2 mg/kg every 12 hours: transient improvement

• Change of DVM internist indicated only an abdominal Rx lateral view:

• “suspicious gastric rotation”, occupying 70-80% of the abdomen

• Referred for surgical consultation

•

Once referred to the surgical office, physical examination determined:

decay, abdominal dilation, moderate abdominal pain in the epi-

mesogastric area.

Emaciated status shown by the patient when received

NO PREOP WORK UP WAS REALIZED BEFORE

To properly evaluate a gastric malposition it is necessary to obtain at

least two radiographs Right lateral and DV or VD

Sometimes a third view from the opposite side, Left lateral, may be

necessary

mechanical alteration that prevent gastric normal emptying

in the inmediate postoperative.

abnormal motility

pyloric stenosisDifferential

Diagnosis l?

PCV, total proteins, albumin, kidney and liver

profile plus coagulogram are repeated, all

values are found within a normal range.

ERROR

fundus

izquierda

derecha

craneal

caudal

stomachfixed to

rightabdominal

woundedge

keepingthe

rotation

theproblemwasn'tsolved

recurrence of signs

general statecommitment

the contiguity of the gastropexy to the midline can be observed.

• Incisional Gastropexy

• Exceedingly long suture line: ~15 cm

fundus

izquierdaderecha

craneal

caudal

The patient’s stomach is exposed,

left hand:

holds the fundus

right hand:

holds the pyloric antrum

the greater curvature of the stomach is found

between the two hands, identified by the

gastroepiploic vessels.

piloro

a la izquierda

fundus a la

derecha

In the previous surgery, the gastric fundus was

pexied

to the right side of the abdomen,

causing a chronic rotation of the stomach and

compromising a normal gastric emptying.

Photo taken from the right side, the blue arrow

indicates the position of the pylorus on the left

side; while the red one points the fundus, on

the right hand side.

GASTROEPIPLOIC AND SPLENIC

VESSELS

INGORGEDCONGESTED

• splenic rotation 180º

• arterial patency control

• look for vein thrombosis (string of pearls)

ERROR

• Freeing up the previous “pexy”

• Losange in right abdominal wall:

to avoid further damage to the chronically distended gastric wall

Dorita was hospitalized under fluid therapy

Continuous infusion of metoclopramide

Ranitidine 2 mg/kg every 12 hs

Sucralfate every 12 HS

Ampicillin Sulbactam 20 mg/kg every 12 hs

Tramadol 2 mg/kg every 8 hs

• Special GI diet food per os when she fully recovered from

anesthesia,

• Small amounts with a frequency of 8 times a day

• Within a week he regained 4 kg of body weight and only

presented one episode of mild gastric dilation, after a ravenous

eating on the second postoperative day

DORITA:10 DAYS AFTER SURGERY.

Incomplete physical exam and evaluation of traumatized

patient

Events linked to each

other

can involve an

implicit

deleatereal action for

the patient

• Female canine, mongrel, 5-years-old

• She fell from a height, and was nailed to the fence of her house

• The first veterinary doctor, surgically resolved the perforation of the abdominal wall

• without performing previously a complete neurological exam, or chest imaging

studies and

• spine.

• When she recovered from anesthesia, she had paraplegic hindlimbs lacking deep pain

sensation

L4 fracture

ERROR

EXTRACTION OF BONE FRAGMENTS, PAINT RESIDUES

SAMPLING FOR CULTIVATION-ANTIBIOGRAM

FIXATION-STABILIZATION

PINS AND PMMA

Postoperative:

Physical rehabilitation

Orthopedic trolley once the spine was welded

Signalment

canine/mongrel shitzu/male/ 3 years old

History:

Right chryptochid.

Five days ago he was castrated via a right-

side celiotomy.

Referred due to a severe pain and

deformation in the surgical wound area.

Clinical Findings:

hyperthermia 40ºC, pink mucous

membranes, CRT1 second, normal

hydration, auscultation within normal limits,

right superficial inguinal LN increased in

size.

abdominal palpation relates intense pain in

hypogastrium

palpable deformation in the right para-

prepucial area

ERROR

When the patient was placed in dorsal

recumbency to check the surgical wound, the

following was found:

wound showing signs of inflammation/infection

deformation under the surgical area

purulent secretion through the most caudal

suture

overlapping of the wound edges

skin area around the wound with no appropriate

trimming

Resolution:

When preparing the surgical field for

surgery, drainage of a large amount of

purulent material, (drained as much as

possible manually) was observed.

Several scrubbings with chlorhexidine

soap and final prep with chlorhexidine

solution

41

surgicalexploration

culture/sensitivitysamples

checkwound/abdomen/spermatic cord

stump

lavaged withsaline

new culture/sensitivity

sampling

final closure: drainage?

• Sutured with linen/large size (not in use anymore)

• Skin edges overlapped

• Inflammation

• Snug sutures, causing increased inflammation

• Partially opened wound

• Skin edge necrosis

apparently suture with a continuous

subcuticular pattern pretending to

leave the final knot on the outside

of the skin

• Why does the overlapping of the wound edges take

place?

• Due to take more tissue on one side of the suture line

compared to the opposite.

• Why a line of necrosis can be observed in one of the

wound’s edges?

• Rough handling of the tissues, associated with excessive

suture tension disturbs the blood supply to the incised skin.

• Inflammation is minimized through delicate tissue handling, strict

aseptic handling,and appropriate instrumentation for each

procedure.

• Pain:

• If the patient feels uncomfortable and want to lick his wound, pay

attention! something could be wrong

• Infection:

• It is not recomended to use of prophylactic antibiotic therapy in

clean surgeries like this that is described here is not indicated.

• infection in this case was caused by incorrect handling of the

aseptic technique.

•

Respect for the patient is

our most precious treasure;

we must take care of it and

should not cause any

further damage when trying

to solve a problem

surgically

• Resolution:

• Repeated sampling for growing-antibiogram (1)

upon entering the abdomen and before closing

(2).

• Extendedd the wound cranially to check the

abdomen and perform a copious washing with

warm saline solution.

• Penrose drain was placed in the subcutaneous

layer, fixed with two separate simple points.

• Wound closure was made in 4 layers (muscular,

subcutaneous, subcuticular and skin) with 3-0

non-absorbable monofilament Nylon, simple

interrupted pattern:

• the edges of the muscle layer were

debrided

• The result of the antibiogram culture 1:

Staph. aureus and E. fecalis. Sensitive to

ceftriaxone, resistant to other antibiotics.

• Patient was treated at a dose of 30 mg/kg

every 12 hours for one week.

• The drain is removed at 72 hours.

• The wound evolved favorably withdrawing

the skin stitches after 7 days.

This case and highlights the

importance of following Halsted’s

principles, of utmost importance to

the success in the surgical treatment

of tissues with minimal damage.

- Soft handling of the tissues:

- Meticulous hemostasis:.

- Preservation of the blood source:

- Strict aseptic technique:

- Minimum tension in the fabrics:

- Precise apposition:

- Avoid leaving death space

Kika meningioma corpus calloso

Transfrontoparietal craniotomy

Fluctuating deformation 10 days

postoperative: Fistula LCR?

Surgical review

CSF fistula resolution

Moon

Operated about a week from a femur fracture, without pre-surgical studies

Arrived with hyperthermia 40.5ºC, decay, hyporexia.

Severe pain and deformation in more in the area of surgery, bleeding over

the proximal region of the wound

Blood count presenting severe anemia, and neutrophilia with high desviousness to the left

Hto 19 High neutrophilia: infection?

Thepatient isadmitted

Startanalgesic

infusion IV

Fluid therapy

antibiotics

Planning Surgicalexploration

and bloodtransfusion

culture: Proteus sensitive to Imipenem

she repeat from clinical signs

And go on deterioration of her status

We decided the amputation of the limb

amputation of the limb

she recovered very well

ERROR

58

actitudes

DON'T RUN AWAY AFTER THE

SURGERY END!

IF YOU HAVE ANOTHER

COMMITMENT, LEARN TO SET THE

AGENDA

AGREE TO BE ABLE TO DO EVERY

JOB CORRECTLY

IF A SURGEON,

DOESN'T KNOW WHAT

HAPPENED TO THAT PATIENT

AFTER THE SURGERY.

BECAUSE HE DOES NOT

FOLLOW ACCORDINGLY:

Peter Douglas

FACEBOOK

THE ANESTESIC PROCESS

DOESN'T CONCLUDE WHEN

WE CLOSE THE ANESTHESIC

VAPORIZER NO CONCLUYO EL

TRATAMIENTO QUIRURGICO

01.NO SURGICAL PROCEDURE IS SIMPLE

02.How a surgeon works in the face of

complications difference

a "great surgeon" of an ”operator"

03.we should operate with the delicacy and

responsibility we would like,

if we were the patient

04. "I can lie to you all,

less myself”

I must be honest with me..

05. The well-being of our patient is our goul

We should not hesitate to ask for help or wait

until we're ready to deal with a difficult case

06.Each case is unique and distinct

We've never seen everything/never

know everything

07.Analyze complications until getting a

conclusion, up to the source.

If we do not understand why they happened,

we are not going to prevent them