A comprehensive primer of surgical informed consent

Informed consent plays a major role in forming a therapeutic alliance with the patient. The informed consent process has evolved from simple consent, in which the surgeon needed only to obtain the patient's permission for a procedure, into informed consent, in which the surgeon provides the patient with information about clinically salient features of a procedure, the patient understands this information adequately, and the patient voluntarily authorizes the surgeon to perform the procedure. Special circumstances of informed consent include conflicting professional opinions, consent with multiple physicians, patients who are undecided or refuse surgery, patients with diminished decision-making capacity, surrogate decision making, pediatric assent, and consent for the involvement of trainees.

Multiperforated atrial septal aneurysm and a single coronary artery

Multiperforated atrial septal aneurysm (ASA) with left-to-right shunt and elevated pulmonary arterial pressure is rare. We present an adult patient with this unusual anomaly combined with a single coronary ostium emerging from the right sinus of Valsalva. The ASA was excised and the defect repaired successfully.

Consultation or corruption? The ethics of signing on to the medical-industrial complex

A prominent vascular surgeon is approached by a representative of a large medical device company with a proposal to implant a new self-sealing patch for closing open carotid endarterectomies. The patch is made of a new synthetic material that establishes immediate hemostasis and inhibits restenosis in animal studies. It has just been approved for human use by the Food and Drug Administration. The cost of the new patch is much higher than for established comparable products, even when potential long-term benefits are considered, but using it would reduce the operative time required for achieving hemostasis. The manufacturer's representative tells you that the company will pay a selected group of vascular surgeons $500 apiece each time they insert the patch on their patients and complete a one-page report. Surgeons with the highest volume of cases utilizing the patch will be offered a paid clinical consultancy with the company. You've used another company's product for several years and found it entirely satisfactory, but have followed development of the new patch with interest and considered trying it in your patients having carotid endarterectomies. What should you do? A. Join the study. You probably would have used the new patch on your patients anyway. B. If the early data warrant, implant the patch on a trial basis without enrolling in the project, and finally decide whether to continue using it based on your clinical experience and additional published reports. C. Call some of the other investigators who have already enrolled in the project and ask them about their experience. D. Decline the invitation immediately. Refuse to ever speak to the representative again. E. Estimate the ability of your patients to sustain the high cost of the new product and decide accordingly whether to use it.

Whodunit? Ghost surgery and ethical billing

A senior vascular surgery resident started an autogenous radical-cephalic arteriovenous fistula procedure on a comatose patient in the surgical intensive care unit (SICU), expecting you to arrive momentarily. You were nevertheless unexpectedly detained establishing hemostasis in the main operating suite. You arrived in the SICU as the dressing was being applied. Fistula flows were excellent and there were no operative complications. The resident who began and finally completed the case was highly skilled and in the final month of his vascular training; you had supervised his satisfactory performance of many procedures like this one during the last 2 years. The patient's elderly wife had consented to the procedure, which she was told you would be directly supervising while the resident performed the surgery. When the operation was over you met with her to explain your emergency conflict and assure her that you checked the resident's work and found it entirely satisfactory. She accepted your explanation and was relieved that the operation went well. The patient's multiple comorbidities nevertheless necessitated an extended postoperative stay in the SICU, where you personally cared for him. The resident had dictated routinely that you attended the procedure, and your billing clerk had no reason to doubt the operative report's accuracy when she submitted your surgical fees to Medicare and the patient's private insurer, which paid to their contractual limits without challenge. On many occasions you have had your billings shorted by both. The resident since has graduated. What should you do?

Informed consent: it's not just signing a form

Informed consent plays a major role in forming a therapeutic alliance with the patient. The informed consent process has evolved from simple consent, in which the surgeon needed only to obtain the patient's permission for a procedure, into informed consent, in which the surgeon provides the patient with information about clinically salient features of a procedure, the patient understands this information adequately, and the patient voluntarily authorizes the surgeon to perform the procedure. Special circumstances of informed consent include conflicting professional opinions, consent with multiple physicians, patients who are undecided or refuse surgery, patients with diminished decision-making capacity, surrogate decision making, pediatric assent, and consent for the involvement of trainees.

Turf wars: The ethics of professional territorialism

A 300-bed general hospital in a mid-sized city has a busy cardiac catheterization laboratory, with 12 invasive cardiologists and more than 4000 annual procedures. An invasive radiology suite, the only one in town, is staffed by a single invasive radiologist and two vascular surgeons. They perform about 150 diagnostic angiograms and endovascular procedures each year, about half of which are generated by consultation requests from the cardiologists. The invasive radiology team has worked together for the last 5 years, since an endovascular fellowship-trained vascular surgeon joined the staff. The invasive radiologist helped to develop an endovascular team and mentored the more senior vascular surgeon until he could accumulate the requisite number of procedures to become credentialed. The program's finances and work schedule have been arranged to the satisfaction of all three participants. Until recently, whenever cardiologists found evidence of vascular occlusive disease during catheterizations, they changed host arteries; if symptoms and signs indicated a need for therapy, they referred patients to the invasive radiology clinic. Lately, the cardiologists have begun to perform terminal angiograms on all their patients to detect injuries. They have requested clinical privileges to perform peripheral endovascular procedures as well as traditional cardiac work. The hospital administrator is fearful that the cardiologists may leave the hospital if their request is denied. The invasive radiology staff are concerned that the caseload is insufficient to maintain quality if they must divide it with the cardiologists. You are the hospital Chief of Staff and must decide whether to grant the cardiologists privileges which have thus far been reserved to the endovascular team. What should you do?

Withdrawal of life-sustaining low-burden care

A 90-year-old diabetic man with unreconstructable peripheral vascular disease, end-stage chronic obstructive pulmonary disease, relentless ischemic rest pain, and severe disability returns to your clinic asking you to deactivate his implanted pacemaker. To do so would likely precipitate his demise, and you ask him if he is aware of this. He tells you that he is and that he has been considering this request since he last saw you 3 months ago. Relief of his chronic pain would require bilateral hip-disarticulating amputations, procedures with a prohibitively high operative mortality rate, particularly with his age and comorbidities. He has been evaluated by a psychiatrist and found to be mentally competent. His treatment by a pain specialist, who used his full armamentarium of high-dose narcotics, electronic devices, nerve blocks, and psychological techniques, has been unsuccessful. You do not reside in Oregon. What is your most ethical course of action?

Ethical nuances of combining romance with medical practice

An elderly, widowed man with early dementia has required several surgical procedures for treatment of peripheral vascular disease over the years. Each of the operations has been performed by a single surgeon, for whom the patient and his family have developed enormous respect and admiration. The patient is quite wealthy, and at the urging of his unmarried adult daughter, his guardian, has endowed a professorship and directed that this surgeon be the first appointment to the new position. The surgeon has recently divorced, and soon after he accepts the medical school offer the daughter invites him to dinner alone at her apartment. What should he do?

Organ-sparing surgical treatment of giant hepatic hydatid cysts

BACKGROUND

Excision of giant hepatic hydatid cysts may be associated with loss of hepatic tissue. We describe a method for obliterating spacious residual cavities that promotes salvage of healthy liver parenchyma.

METHODS

After simple cystectomy, the residual cavity is obliterated by manual compression of the healthy liver parenchyma from the left and right toward the midline of the cavity. While compression is maintained, the approximated edges of the cyst's fibrous capsule are closed with mattress sutures. Omentoplasty or gelatine sponges are used to fill the dead space prior to suturing of the fibrous capsule.

RESULTS

The method was used in 8 patients between 1993 and 2000. No sepsis, postoperative bile leak, or other complications occurred. No long-term adverse effects were found.

CONCLUSIONS

This method is simple and effective for obliteration of extremely large residual cavities after cystectomy for liver hydatidosis. It may be used safely in selected patients.

Recurrent intercostal herniation of the liver

Abdominal intercostal hernia occurs rarely, with only 26 previous cases reported in the professional literature. A 51-year-old man presented with a painful right chest protrusion. One year earlier he had experienced a severe coughing spell and spontaneous rib fracture and chest protrusion. He was treated with endogenous tissue reinforcement and had no clinical improvement. Magnetic resonance imaging revealed the liver protruding through the chest wall. The hernia was reduced and the chest wall was repaired with prosthetic mesh and cables. Attention to the chest wall anatomy and reliable tissue closure including pericostal or transcostal nonabsorbable sutures and a prosthetic bridge over the defect are the best way to eliminate the patient's risk for recurrence.