Anita Kurmann

Adverse effect of noise in the operating theatre on surgical-site infection

The aim of this pilot study was to evaluate the noise level in an operating theatre as a possible surrogate marker for intraoperative behaviour, and to detect any correlation between sound level and subsequent surgical‐site infection (SSI).

Long-term follow-up of a randomized controlled trial of Lichtenstein's operation versus mesh plug repair for inguinal hernia.

Objective:To compare long-term results of Lichtensteins operation versus mesh plug repair for open inguinal hernia repair. Background:The technique of best choice in open prosthetic inguinal hernia repair remains a subject of ongoing debate. Methods:In this prospective, randomized controlled multicenter trial, patients with primary or recurrent inguinal hernias were randomized to undergo either Lichtensteins operation or mesh plug repair. The primary endpoint was the long-term recurrence rate. Secondary endpoints included chronic pain, sensibility disorders, and reoperation rate. Results:In total, 697 hernias in 594 patients were randomized (297 patients per group). At a median follow-up of 6.5 years, 528 (76%) operated hernias in 444 (75%) patients were clinically evaluated. The recurrence rate was similar in both groups [mesh plug: 21/268 hernias = 7.8%; Lichtenstein: 21/260 hernias = 8.1%; adjusted odds ratio (OR): 0.92; 95% confidence interval (CI): 0.51, 1.68; P = 0.795]. We did not find a significant difference for chronic pain (Visual Analog Scale score >3) (OR: 0.58; 95% CI: 0.31, 1.09; P = 0.088) and sensory testing (17% vs 20% of patients; OR: 0.53; 95% CI: 0.21, 1.37; P = 0.190) between the 2 groups. There were less reoperations in the mesh plug than in the Lichtensteins operation group (OR: 0.43; 95% CI: 0.22, 0.85; P = 0.016). Conclusions:The long-term results of this trial indicate not enough evidence for differences in recurrence, chronic pain, and sensibility disorders between mesh plug repair and Lichtensteins operation but a lower likelihood for reoperation for mesh plug repair. Estimates for all endpoints were statistically not significant or based on large CIs. Clinical Trials Registration:ClinicalTrials.gov Identifier: NCT01637818.

Effect of intraoperative infiltration with local anesthesia on the development of chronic pain after inguinal hernia repair: A randomized, triple-blinded, placebo-controlled trial

BACKGROUND Chronic pain is a common complication after inguinal hernia repair. The objective of this randomized trial was to assess the effect of intraoperative infiltration with local anesthetic versus placebo on the development of chronic pain after inguinal hernia repair. METHODS Patients with single- or double-sided inguinal hernia were enrolled in a randomized, controlled, triple-blinded trial with a sequential adaptive design. Hernias were randomized to 1 of 2 treatment groups. The intervention group received a local infiltration of 20 mL bupivacaine 0.25% and the placebo group 20 mL saline 0.9% at the end of the operation. Two interim analyses were performed according to predefined stopping criteria allowing for design and sample size adaption. The primary endpoint was chronic pain defined on a visual analog scale (VAS) as ≥30 in any quality (at rest, lying, walking, climbing stairs, and bending over) 3 months postoperatively. A logistic regression model was built to compare the incidence of chronic pain using generalized estimating equations to adjust for clustering in bilateral hernias. RESULTS Among 357 patients, there were 406 hernias randomized. A total of 5.8% (10/173) experienced VAS ≥ 30 in any quality in the intervention group and 2.3% (4/174) in the placebo group (P = .114) at 3 months postoperatively. Multivariable analysis revealed no evidence of between-group differences for the development of any pain (odds ratio [OR], 1.03; 95% CI, 0.67-1.57; P = .905), whereas preoperative pain was an independent risk factor (OR, 2.52; 95% CI, 1.12-5.68; P = .025). CONCLUSION We did not find any evidence that intraoperative infiltration of local anesthetic had an impact on the development of chronic postoperative pain.

Impact of case-relevant and case-irrelevant communication within the surgical team on surgical-site infection.

Surgical‐site infections (SSIs) are the most common complications after surgery. An influence from talking and distractions during surgery on patient outcomes has been suggested, but there is limited evidence. The aim of this prospective observational study was to assess the relationship between intraoperative communication within the surgical team and SSI, and between intraoperative distractions and SSI.

Assessing distractors and teamwork during surgery: developing an event-based method for direct observation

Objective To develop a behavioural observation method to simultaneously assess distractors and communication/teamwork during surgical procedures through direct, on-site observations; to establish the reliability of the method for long (>3 h) procedures. Methods Observational categories for an event-based coding system were developed based on expert interviews, observations and a literature review. Using Cohens κ and the intraclass correlation coefficient, interobserver agreement was assessed for 29 procedures. Agreement was calculated for the entire surgery, and for the 1st hour. In addition, interobserver agreement was assessed between two tired observers and between a tired and a non-tired observer after 3 h of surgery. Results The observational system has five codes for distractors (door openings, noise distractors, technical distractors, side conversations and interruptions), eight codes for communication/teamwork (case-relevant communication, teaching, leadership, problem solving, case-irrelevant communication, laughter, tension and communication with external visitors) and five contextual codes (incision, last stitch, personnel changes in the sterile team, location changes around the table and incidents). Based on 5-min intervals, Cohens κ was good to excellent for distractors (0.74–0.98) and for communication/teamwork (0.70–1). Based on frequency counts, intraclass correlation coefficient was excellent for distractors (0.86–0.99) and good to excellent for communication/teamwork (0.45–0.99). After 3 h of surgery, Cohens κ was 0.78–0.93 for distractors, and 0.79–1 for communication/teamwork. Discussion The observational method developed allows a single observer to simultaneously assess distractors and communication/teamwork. Even for long procedures, high interobserver agreement can be achieved. Data collected with this method allow for investigating separate or combined effects of distractions and communication/teamwork on surgical performance and patient outcomes.

Morbidity rate of reoperation in thyroid surgery: a different point of view

BACKGROUND Goitre recurrence is a common problem following subtotal thyroid gland resection for multinodular goitre disease. The aim of the present study was to evaluate morbidity rate in relation to the side of initial and redo-surgery for recurrent disease. METHODS A total of 1699 patients underwent consecutive thyroid gland surgery between 1997 and 2010 at our institution. One hundred and eighteen patients (6.9%) underwent redo-surgery for recurrent disease after subtotal resection. One hundred and nine patients with complete follow-up were included in the present study. RESULTS Recurrent disease was found in 79 patients (72.5%) in the ipsilateral lobe and in 30 patients (27.5%) in the contralateral lobe. The incidence of permanent recurrent laryngeal nerve palsy was significantly higher in patients undergoing redo-surgery on the ipsilateral lobe compared to patients undergoing initial operation (3.8% vs. 1.1%; p = 0.03), whereas no difference was found in patients with contralateral redo-surgery compared to patients undergoing initial operation (p = 1.0). Independent risk factors for contralateral recurrent disease were age at primary operation <37 years (OR 4.86; 95% CI 1.58-15.01) and time to recurrence <20 years (OR 6.53; 95% CI 2.23-19.01). CONCLUSION Morbidity rate for recurrent disease after subtotal resection was significantly higher for ipsilateral redo-surgery compared to initial surgery, whereas redo-surgery can be performed safely on the contralateral lobe. Young age at primary operation and short time to recurrence are independent risk factors for contralateral recurrent disease.

Hepatic steatosis is associated with surgical-site infection after hepatic and colorectal surgery

BACKGROUND Obesity and increased visceral fat deposits are important risk factors for surgical-site infection (SSI). Interestingly, a potential role of hepatic steatosis on complications after extrahepatic surgery remains unknown. The aim of the present study was to investigate the impact of hepatic steatosis on SSI in patients that underwent open abdominal surgery. METHODS A total of 231 patients that underwent either liver (n = 116) or colorectal (n = 115) resection and received preoperative contrast-enhanced computed tomography scans were retrospectively investigated. Signal attenuation of the liver parenchyma was measured on computed tomography scans to assess hepatic steatosis. RESULTS More SSIs (including types 1, 2, and 3) were found in the group with hepatic steatosis (56/118 [47.5%]) compared with the control group (30/113 [26.6%]; P = .001). Patients with hepatic steatosis showed greater median body mass index than patients without hepatic steatosis (26.6 kg/m(2) [range 16.8-47.0 kg/m(2)] vs 23.2 kg/m(2) [15.9-32.7 kg/m(2)]; P < .001). Patients with hepatic steatosis experienced longer median operation times (297 minutes [52-708 minutes] vs 240 minutes [80-600 minutes]; P = .003). In a multivariate analysis, hepatic steatosis was identified as an independent risk factor for SSI in patients undergoing hepatic (odds ratio 10.33 [95% confidence interval 1.19-89.76]; P = .03) or colorectal (odds ratio 6.67 [95% confidence interval 1.12-39.33]; P = .04) operation. CONCLUSION Hepatic steatosis is associated with SSI after hepatic and colorectal operation.

Noise peaks influence communication in the operating room. An observational study

Abstract Noise peaks are powerful distractors. This study focuses on the impact of noise peaks on surgical teams’ communication during 109 long abdominal surgeries. We related measured noise peaks during 5-min intervals to the amount of observed communication during the same interval. Results show that noise peaks are associated with less case-relevant communication; this effect is moderated by the level of surgical experience; case-relevant communications decrease under high noise peak conditions among junior, but not among senior surgeons. However, case-irrelevant communication did not decrease under high noise level conditions, rather there was a trend to more case-irrelevant communication under high noise peaks. The results support the hypothesis that noise peaks impair communication because they draw on attentional resources rather than impairing understanding of communication. As case-relevant communication is important for surgical performance, exposure to high noise peaks in the OR should be minimised especially for less experienced surgeons. Practitioner Summary: This study investigated whether noise during surgeries influenced the communication within surgical teams. During abdominal surgeries, noise levels were measured and communication was observed. Results showed that high noise peaks reduced the frequency of patient-related communication, but did not reduce patient-irrelevant communication. Noise may negatively affect team coordination in surgeries.