Consent for post-operative visual loss in prone spinal surgery: aligning clinical practice with legal standards

Perioperative visual loss and consent for adult spine surgery: a national survey of the practice amongst spine surgeons and anaesthetists†

BACKGROUND

Perioperative Visual Loss (POVL) is a devastating complication for patients undergoing spine surgery. Consent process for POVL amongst spine surgeons and anaesthetist remains variable. The aim of this study is to evaluate their practice and views about it.

METHODS

Two similar questionnaires were distributed to members of the Society of British Neurological Surgeons (SBNS), British Association of Spine Surgeons (BASS), and Neuroanaesthsia and Critical Care Society (NACCS).

RESULTS

A total of 271 responses were received (SBNS/BASS n = 149, NACCS n = 122). Fewer surgeons considered POVL as a material risk for patients compared to the anaesthetists (57.7 versus 79.7%). Outpatient/pre-assessment clinics were considered as the optimal setting for discussing POVL by the majority of the clinicians (81.2 and 93.4%). POVL should be discussed by both specialists according to 75% of the anaesthetists. Estimated incidence of POVL was considered to be higher by the anaesthetists (0.03-0.2% by 63% of the anaesthetist versus 0.0001-0.004% by 57% of the surgeons). Twenty-three surgeons and 10 anaesthetists had a patient who suffered from POVL, which led to a change of practice in most of them. This questionnaire will lead to a change in practice/consent to 18.1% of the surgeons and 23.5% of the anaesthetists.

CONCLUSIONS

Most of the surgeons and anaesthetist feel that POVL is a material risk that ideally needs to be firstly discussed before the day of surgery, by both specialties. However, a significant number of clinicians have an opposite view. A national guidance from respective societies should encourage POVL to be discussed routinely.

Patient Positioning in Spine Surgery: What Spine Surgeons Should Know?

Spine surgery has advanced tremendously over the last decade. The number of spine surgeries performed each year has also been increasing constantly. Unfortunately, the reporting of position-related complications in spine surgery has also been steadily increasing. These complications not only result in significant morbidity for the patient but also raises the risk of litigation for the surgical and anesthetic teams. Fortunately, most position-related complications are avoidable with basic positioning knowledge. Hence, it is critical to be cautious and take all necessary precautions to avoid position-related complications. We discuss the various position-related complications associated with the prone position, which is the most commonly used position in spine surgery, in this narrative review. We also discuss the various methods for avoiding complications. Furthermore, we briefly discuss less commonly used positions in spine surgery, like the lateral and sitting positions.

Comparison of intraocular pressure during laparoscopic totally extraperitoneal (TEP) versus transabdominal preperitoneal (TAPP) inguinal hernia repair

BACKGROUND

Laparoscopic totally extraperitoneal (TEP) repair and transabdominal preperitoneal (TAPP) repair are standard laparoscopic procedures for inguinal hernia repair. Some evidence has shown that pneumoperitoneum can cause an increase in intraocular pressure (IOP) during surgery. This study aimed to compare intraoperative IOP following extraperitoneal CO₂ insufflation with the TEP approach and intraperitoneal CO₂ insufflation with the TAPP approach.

METHODS

This study is a prospective cohort study. Patients who had inguinal hernias suitable for laparoscopic inguinal hernia repair were assigned to undergo the TEP or TAPP approach. We measured preoperative, intraoperative, and postoperative IOP. The IOP of the TEP and TAPP groups was evaluated using a t test. The relations between peak inspiratory pressure (PIP), mean arterial pressure (MAP), and end-tidal CO₂ (EtCO₂) were estimated using ANOVA. Univariate and multivariate analyses were performed to determine the factors associated with IOP.

RESULTS

There were 50 patients in this study (TEP group n = 25, TAPP group n = 25). The change in intraoperative IOP from the preoperative measurement to the measurement after CO₂ insufflation was not statistically significant in either the TEP or TAPP group (p value = 0.357). There was no significant difference in intraoperative IOP change between the TEP and TAPP groups. Intraoperative MAP and PIP were related to IOP, but intraoperative EtCO2 was not.

CONCLUSIONS

There was no significant intraoperative IOP change during laparoscopic inguinal hernia repair. Both the TEP and TAPP techniques can be performed safely without increasing intraoperative IOP.

Liminal spaces in neurosurgery - tensions between expectations of the patient and their surgeon at the threshold of informed consent

Purpose: The concept of 'liminality', describing the universal human experience of transition in status, has been shown to be relevant in addressing the provision of healthcare needs within clinical medicine. Consent may be viewed as a threshold which patients must cross between a state of integration of information to a state of transformation into knowledge. This article reframes gaps in the modern surgical approach to the process of 'informed consent' via the lens of liminality, drawing on key illustrative cases from the medicolegal evolution in the UK and Commonwealth.Materials and methods: A focused literature search was performed for informative medical legal cases addressing or contributing to the understanding of "informed consent". Searches and references to sources of case law were performed using Westlaw and Hein Online databases. Searches for secondary sources for interpretation and discussions of case law and concepts, as well as topics of liminality and autonomy, were performed via PubMed and Academia databases and relevant online resources.Results: The paper organizes the illustrative material using the following approach:- a discussion and dissection of the i) evolution of consent as a duty to warn, comprising a summary of landmark cases, ii) materiality of risks and what a particular patient would wish to know and iii) conceptual relevance of troublesome knowledge, relational autonomy and threshold concepts in learning to key examples in case law and the process of informed consent.Conclusions: Modern surgical practice of informed consent must strive for clarity of mutual understanding. The framework of liminality allows us to understand the in-between states encountered during the patient's journey. An ability to recognize such gaps in expectations, and develop tools to promote transformational learning, would allow the surgeon to evolve from prudent practitioner to patient mentor at the threshold of informed consent.