'Will you be doing my operation doctor?' Patient attitudes to informed consent

BACKGROUND

As part of the consent process, it is part of a doctor's duty of care to reveal any material risk. Depending upon the level of supervision, whether the operating surgeon is a trainee may be such a risk, but in our experience this is not routinely discussed with patients pre-operatively. We set out to discover patients' attitudes to being operated on by trainee urological surgeons.

PATIENTS AND METHODS

A total of 101 completed questionnaires were received from patients (90 male, 11 female, mean age 72 years) undergoing transurethral resection of the prostate (TURP), transurethral resection of a bladder tumour (TURBT) or cystodiathermy on various aspects of their attitudes to being operated on by junior doctors as part of training.

RESULTS

The response rate was 77%. Of the respondents, 94 patients (91%) thought that junior doctors should perform surgery as part of their training. Only 11 of 73 (15%) said they would be happy for a junior doctor, competent to perform the procedure, to operate unsupervised. Of 98 patients, 80 (82%) thought they should be told if the operation was going to be performed by a junior doctor, and 85 (87%) that they should be told their name and designation.

CONCLUSIONS

For consent to be 'informed', the experience and identity of the surgeon should be made known to patients. Most patients are happy to be operated on by a junior doctor under consultant supervision, but would want to be told and know their name and status.

Use of the ultrasonic dissecting scalpel in laparoscopic cholecystectomy

BACKGROUND

We evaluated the use of the ultrasonically activated (harmonic) scalpel (HS) in the performance of laparoscopic cholecystectomy (LC).

METHODS

A total of 282 consecutive patients, 64 of whom had acute cholecystitis at the time of surgery, underwent LC using HS dissection. Indications for surgery included chronic pain (180 cases), episodes of acute cholecystitis (89 cases), pancreatitis (five cases), and jaundice (seven cases). Twenty-seven patients had preoperative endoscopic retrograde cholangiopancreatography (ERCP).

RESULTS

The mean operating time was 29 +/- 9 mins. Eleven procedures were converted to open surgery, (four due to bleeding, six due to unclear anatomy, and one due to an inflammatory mass caused by gangrene/perforation). Complications occurred in 14 patients. They included minor port site infection (four cases), pulmonary atelectasis (three cases), urinary retention (two cases), intraoperative catheterization not routinely performed, bile leak (two cases, both from cystic duct; one of the cystic duct leaks occurred because of dislodgement of the occluding clip, the other may have been due to duct injury from the clip), pulmonary embolus (one case), and myocardial infarction (one case). Neither of the latter complications were fatal. One patient required a postoperative transfusion due to a fall in hematocrit of 3.2 gr/dl.

CONCLUSIONS

LC performed with the HS is feasible and effective. Operating time and blood loss were minimal, and the conversion rate was low (3.9%). There were no bile duct injuries. Use of the HS makes dissection easier, thereby helping to reduce operative time and lower the need for conversion to open surgery.

A prospective randomized trial of intraoperative bupivacaine irrigation for management of shoulder-tip pain following laparoscopy

BACKGROUND

Postoperative shoulder-tip pain (STP) frequently occurs following laparoscopic surgery. In an attempt to abrogate this complication we prospectively evaluated the efficacy of intraoperative irrigation of the diaphragm with bupivacaine.

METHODS

One hundred and five consecutive patients undergoing laparoscopic surgery were prospectively randomized to treatment or control groups. Treatment group (B, n = 55) received irrigation with 10 mL 0.5% bupivacaine in 500 mL saline and control group (A, n = 50) received an equal volume of normal saline. Each dome of the diaphragm was irrigated with 250 mL of either solution at the end of surgery. Laparoscopic procedures performed included cholecystectomy (n = 63), Nissen fundoplication (n = 21), appendicectomy (n = 7), hernia repair (n = 4), and diagnostic laparoscopy (n = 10). Patients' anesthesia and perioperative analgesia were standardized. STP was recorded on a visual analogue pain scale (VAPS) in the recovery room immediately following surgery and at 4, 10, and 24 hours thereafter.

RESULTS

The overall incidence of STP in patients undergoing laparoscopic procedures was approximately 24%. Twenty-one patients (42%) in the control group and 4 patients (7%) in the treatment group complained of shoulder pain during the recording period (P = 0.003). Mean STP scores as recorded on VAPS were significantly lower in the bupivacaine group than in the control group from 4 to 24 hours after surgery (P < 0.01). Postoperative analgesia requirements were also significantly reduced in those patients receiving bupivacaine irrigation (P < 0.04).

CONCLUSION

Intraperitoneal irrigation with bupivacaine to both hemidiaphragms at the end of surgery significantly reduces both frequency and intensity of STP following laparoscopic procedures thus reducing patient morbidity.