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Lessons learned by personal failures in aneurysm surgery: what went wrong, and why?
1Section for Neurosurgery, Department of Surgical Sciences, University of Bergen, 5021, Bergen, Norway. knut.gustav.wester@helse-bergen.no
Purpose:
To analyse the intraoperative complications of a single neurosurgeon, with emphasis on devastating intraoperative incidents, and how they possibly could have been avoided.
Methods:
All the patients operated upon by the author between 1986 and 2002, i.e. 252 patients with 270 craniotomies for 294 aneurysms, were included. All intraoperative events that possibly could have influenced the clinical outcome were recorded prospectively.
Results:
A total of 16 cases (6.3% of all the patients) with serious intraoperative incidents were identified. In 11 cases (3.6% of all aneurysms), an intraoperative rupture occurred that was judged to have had mild to severe consequences for the patient. In another four patients (1.6% of all patients), all with unruptured, large aneurysms (>15 mm) of the carotid or middle cerebral arteries, a major vessel occlusion occurred inadvertently. In one patient with a large, unruptured MCA aneurysm, a clip slipped after the closure of the wound, causing a fatal intracerebral haemorrhage. These events had a severe impact on the clinical outcome. In retrospect, most of these incidents could, and should have, been avoided.
Conclusions:
It is recommended to start the training of new aneurysm surgeons on patients with small, supratentorial, unruptured aneurysms, followed by ruptured aneurysms in all other supratentorial locations than the anterior communicating artery (ACOM), which is the supratentorial location that should be the last step in the training of independent aneurysm surgeons.
Insights
Serious intraoperative incidents during aneurysm surgery, including ruptures and vessel occlusions, occurred in 6.3% of patients. Most of these devastating events could have been avoided with proper training and surgical planning.
Area of Science:
- Neurosurgery
- Vascular Surgery
- Surgical Outcomes
Background:
- Intraoperative complications can significantly impact patient outcomes in neurosurgery.
- Analyzing specific surgeon's incidents provides insights into preventable errors.
Purpose of the Study:
- To analyze intraoperative complications encountered by a single neurosurgeon.
- To identify devastating intraoperative incidents and explore potential avoidance strategies.
Main Methods:
- Retrospective analysis of 270 craniotomies performed by one surgeon between 1986 and 2002.
- Prospective recording of all intraoperative events potentially influencing clinical outcomes.
Main Results:
- 16 serious intraoperative incidents (6.3%) were identified.
- Intraoperative rupture occurred in 3.6% of aneurysms, with mild to severe consequences.
- Major vessel occlusion occurred in 1.6% of patients, and a fatal intracerebral hemorrhage resulted from a clip slip in one case.
Conclusions:
- Most identified intraoperative incidents were deemed avoidable.
- Training for new aneurysm surgeons should progress from simple to complex cases, starting with small, unruptured aneurysms and concluding with anterior communicating artery aneurysms.
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