The Prevention of Positioning Injuries during Gynecologic Operations. Guideline of DGGG (S1-Level, AWMF Registry No. 015/077, February 2015)

Leading Causes of Anesthesia-Related Liability Claims in Ambulatory Surgery Centers

OBJECTIVE

We present a contemporary analysis of patient injury, allegations, and contributing factors of anesthesia-related closed claims, which involved cases that specifically occurred in free-standing ambulatory surgery centers (ASCs).

METHODS

We examined ASC-closed claims data between 2007 and 2014 from The Doctors Company, a medical malpractice insurer. Findings were coded using the Comprehensive Risk Intelligence Tool developed by CRICO Strategies. We compared coded data from ASC claims with hospital operating room (HOR) claims, in terms of injury severity category, nature of injury, nature of allegation, contributing factors identified, and contributing comorbidities and claim value.

RESULTS

Ambulatory surgery center claims were more likely to be classified as medium severity than HOR claims, more likely to involve dental damage or pain than HOR claims, but less likely to involve death or respiratory or cardiac arrest. Technical performance was the most common contributing factor: 47% of ASCs and 48% of HORs. Only 7% of allegations relating to technical performance were judged to be a direct result of poor technical performance. The most common anesthesia procedures resulting in ASC claims were injection of anesthesia into a peripheral nerve (34%) and intubation (29%). Obesity was the most common contributing comorbidity in both settings. Mean closed claim value was significantly lower for ASC than HOR claims, averaging US $87,888 versus $107,325.

CONCLUSIONS

Analysis of ASC and HOR claims demonstrates significant differences and several common sources of liability. These include improving strategies for thorough screening, preoperative assessment and risk stratifying of patients, incorporating routine dental and airway assessment and documentation, diagnosing and treating perioperative pain adequately, and improving the efficacy of communication between patients and care providers.

The Safe Practice of Female Genital Plastic Surgery

The purpose of this article is to guide surgeons in the safe practice of female genital plastic surgery when the number of such cases is steadily increasing. A careful review of salient things to look for in the patient’s motivation, medical history, and physical examination can help the surgeon wisely choose best candidates. The anatomy is described, with particular attention given to the variations not generally described in textbooks or articles. Descriptions are included for labiaplasty, including clitoral hood reduction, majoraplasty, monsplasty, and perineoplasty with vaginoplasty. Reduction of anesthetic risks, deep venous thromboses, and pulmonary emboli are discussed, with special consideration for avoidance of nerve injury and compartment syndrome. Postoperative care of a variety of vulvovaginal procedures is discussed. Videos showing anatomic variations and surgical techniques of common female genital procedures with recommendations to reduce the complication rate are included in the article.

Lithotomy versus Prone Position for Perianal Surgery: A Randomized Controlled Trial

Purpose

Studies objectively comparing lithotomy and prone positions regarding surgeon comfort, ergonomics, patient comfort, and position related complications are scarce.

Methods

The patients posted for surgery of either fistula in ano, hemorrhoids, or were included in this study. Subjective Mental Effort Questionnaire (SMEQ) and Local Experienced Discomfort (LED) scale were used to score the level of mental and physical stress among the operating surgeon, assistants, and the scrub nurse. Other parameters studied were the exposure of the operative site, patient comfort level, and position-related complications.

Results

Thirty patients were operated in each position. Mean ± standard deviation of jackknife prone vs. lithotomy surgeon SMEQ score (15.6 ± 10.4 vs. 107.0 ± 11.5, P < 0.05) and LED score (1.8 ± 1.5 vs. 6.7 ± 0.5, P < 0.05) were found to be statistically significant. Prone vs. lithotomy assistant SMEQ score (29.1 ± 13.1 vs. 100.6 ± 8.7, P < 0.05) and LED score (4.6 ± 1.1 vs. 7.4 ± 0.8, P < 0.05) were also found to be statistically significant. SMEQ (10.0 ± 0.0 vs. 20.6 ± 2.5, P < 0.05) and LED scores (1.1 ± 0.3 vs. 3.3 ± 0.5, P < 0.05) of scrub nurses and LED scores (2.5 ± 0.5 vs. 6.3 ± 0.7, P < 0.05) of patients were also statistically significant. Exposure of the operative site was significantly better in the prone position (5.0 vs. 2.1, P < 0.05).

Conclusion

Significantly better SMEQ, LED, and exposure score suggests the superiority of jackknife prone position over the lithotomy in terms of significantly less mental and physical stress to the operating surgeon, assistant, and scrub nurse; better ergonomics, and excellent exposure.

Integrative Review of Lower Extremity Nerve Injury During Vaginal Birth

OBJECTIVE

To describe the incidence, health effects, risk factors, and practice implications of lower extremity nerve injury (LENI) related to vaginal births.

DATA SOURCES

We searched MEDLINE, CINAHL, and PubMed from 2000 to 2020 for peer-reviewed published case reports and research studies of LENI related to vaginal births.

STUDY SELECTION

We identified 188 potential records, and 20 met inclusion criteria (six research studies and 14 case studies).

DATA EXTRACTION

Three independent reviewers extracted details of injuries and births into an Excel spreadsheet and analyzed data using SPSS.

DATA SYNTHESIS

Using birth data from each case study and from four of the six research articles, we found the incidence of LENI in vaginal births was 0.3% to 1.8%. The description of health effects includes affected nerves and the location, description, and duration of symptoms. Analyses of risk factors were limited by missing birth data (length of second stage, birth weight, etc). Vaginal births with LENI were 76% spontaneous, 77% with neuraxial anesthesia, and 64% first vaginal birth. Practice implications focused on prevention through specific positioning strategies. Despite nurses being the primary caregivers during labor, LENI was reported most often in anesthesia journals with virtually no reports in nursing journals.

CONCLUSION

LENI is a potential complication of vaginal birth, and little published research is available on prevention and prognosis. While obstetric and anesthesia factors can cause or contribute to nerve injury, LENI is usually caused by positioning and is considered preventable. Care recommendations include the following: avoid prolonged hyperflexion of women's thighs and knees; minimize time in lithotomy, squatting, or kneeling positions; prevent hand or other deep pressure on lateral knee and posterior thigh areas; avoid motor-blocking neuraxial (epidural) anesthesia; and implement frequent repositioning. The paucity of literature contributes to the lack of awareness of LENI among clinicians.

Perioperative management of positioning in gynecological cancersurgery: a national NOGGO-AGO intergroup survey

INTRODUCTION

The daily clinical routine in the operating room includes patient positioning. The number of perioperative positioning-related complications is growing, along with the legal proceedings concerning this topic, and only a few guidelines exist to provide specific recommendations. The aim of this survey was to assess perioperative positioning and associated adverse events during gynecological cancer surgery in Germany.

METHODS

A total of 633 gynecological departments of primary, secondary, and maximum healthcare hospitals in Germany were invited to participate in this multiple-choice online questionnaire. The survey was conducted anonymously for a period of six months. The survey was divided into five different sections: descriptive information about the respondent department, pre- and postoperative management, management of positioning in the operating room based on two fictional case examples, and quality management.

RESULTS

The response rate of our survey was 29.1 % (184/633). Nearly half of the departments (46.7 %) reported to have had one to five patients with positioning-related complications during the prior 12 months, and 29.1 % had experienced a legal dispute due to positioning-related complications. Departments with more than 50 gynecologic-oncological surgeries per year more often reported positioning-related complications (p=0.003). Standard operating procedures exist in almost every department for laparoscopic (97 %) and open surgery (95.1 %), respectively.

DISCUSSION

The high number of positioning-related complications throughout all departments of different healthcare levels underlines the relevance of this issue and supports the need for a prospective European registry for further analysis. Training and education for all staff members should be routinely implemented to reduce and prevent positioning-related complications.

Candy Cane Compared With Boot Stirrups in Vaginal Surgery: A Randomized Controlled Trial

OBJECTIVE

To evaluate differences in physical function at 6 weeks after vaginal surgery among women positioned in candy cane and boot stirrups.

METHODS

We conducted a single-masked, randomized controlled trial of women undergoing vaginal surgery with either candy cane or boot stirrup use. The primary outcome was a change in the PROMIS (Patient-Reported Outcomes Measurement Information System) physical function short form-20a from baseline to 6 weeks after surgery. To achieve 80% power to detect a moderate Cohen effect (d=0.5), we required 64 participants in each group.

RESULTS

From March 2018 to October 2019, 141 women were randomized, and 138 women (72 in the candy cane group and 66 in the boot stirrup group) were included in the final analysis. There were no baseline differences in participant characteristics including age, body mass index, comorbidities, or preoperative history of joint replacements. There were no between-group differences in surgery type, duration of surgery, estimated blood loss, or adverse events at 6 weeks postoperation. Participants in the candy cane group demonstrated worse physical function at 6 weeks compares with the improvement seen in those in the boot stirrup group; this was significantly different between groups (-1.9±7.9 candy cane vs 1.9±7.0 boot, P<.01).

CONCLUSION

Women undergoing vaginal surgery positioned in boot stirrups have significantly better physical function at 6 weeks after surgery when compared with women positioned in candy cane stirrups.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03446950.