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| EDITORIAL COMMENTARY |
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| Year : 2019 | Volume
: 65
| Issue : 1 | Page : 7-8 |
Time duration of an emergency pediatric laparotomy can impact its outcome
P Kothari
Department of Pediatric Surgery, LTMG Hospital, Mumbai, Maharashtra, India
| Date of Web Publication | 28-Jan-2019 |
Correspondence Address:
Dr. P Kothari
Department of Pediatric Surgery, LTMG Hospital, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jpgm.JPGM_240_18
How to cite this article:
Kothari P. Time duration of an emergency pediatric laparotomy can impact its outcome. J Postgrad Med 2019;65:7-8 |
Emergency laparotomies in children are associated with significant morbidity and mortality. Kaushal-Deep et al[1] have conducted a timely and innovative study to identify the optimum time duration for completion of emergency laparotomies to ensure a good outcome. Their study population included children in the age group of 5–10 years presenting in their emergency department with Pediatric Risk of Mortality III score ≤8 and undergoing emergency laparotomy.[1] The present study results indicate that, in a resource-limited setting, when an emergency pediatric laparotomy is completed within 100 min the mortality rate is minimal (1%–2%). However if laparotomy duration increases, then the mortality rate too increases; being an acceptable limit (≈5%) at a cut-off operative duration of 123.5 min. The study concludes with a emphatic statement that “an emergency pediatric laparotomy must not exceed 135 min in any situation as survival function decreases rapidly beyond this point”.[1]
These 100, 123.5, and 135 minutes cut-offs have been decided by the present study after analyzing their outcome results in a robust fashion. These time duration cut-off will serve as valuable guidelines for pediatric surgeons and trainees working in a busy public hospital under stress and at times in sub-optimal conditions.
Apart from keeping an eye on the time duration of an emergency laparotomy, there are some other factors which can help improve the outcome. In the present study, residents and support staff were rotated as per duty protocols. But for better outcome, in future, two trained teams dedicated to handle emergencies should be formed to decrease morbidity and mortality. This factor may assume significance as many studies have shown surgical teamwork to be a factor that affects patient's outcomes.[2],[3]
The time to surgery from the onset of illness/the acute event is another important factor that can affect the outcome of an emergency laparotomy. Delay in diagnosis, decision making, and assessment and work-up adversely affect patient outcome. Factors that cause delay should be tackled and negated effectively. This includes developing standard protocols for the management of emergencies as well as training staff and paraclinical personnel.
There are other well-established outcome predictors which include:[4]
- Status of the patient on arrival (tachycardia, sepsis, capillary refill time, and requirement of inotropes),
- Mental status,
- Preoperative time,
- Anesthesia management,
- Availability of equipment, drugs, and blood,
- Intraoperative pathology, and
- Postoperative care (intensive care unit, ventilator, and inotropes)
In the present study[1] most of the patients were operated upon by trainee doctors and this factor too could have influenced the results. The present study indirectly highlights the need for optimal training of resident surgeons. The over-worked pediatric surgery faculty in public hospitals bears this immense responsibility to ensure that their trainee doctors receive optimal training. Also optimal evaluation of their surgical skills is of paramount importance. The education of surgical trainees should be based on an accurate evaluation of their surgical skill levels. The Objective Structured Assessment of Technical Skills (OSATS) is used for this purpose.[5],[6]
Global rating scale of operative performance includes:[5],[6]
- Respect for tissue
- Time and motion
- Instrument handling
- Knowledge of instrument and disease
- Flow of operation
- Use of assistants
- Knowledge of specific procedures
- Expertise of specialist handling the patient.
The present study[1] is important because till now there has been no study that has predicted mortality as a function of operative duration in emergency laparotomies. However it must be kept in mind that, the best surgeons operate slowly but think quickly; the speed with which a procedure is performed should not be erroneously used as a proxy for competence. A trainee surgeon may try to impress the attending senior surgeon with quick and even ostentatiously elegant manoeuvres leading to operative errors, both minor and major. The best surgeons never seem to be in a hurry. Deliberate, precise movements, without any wasted motions and following the right planes results in a successful surgery. A competent surgeon's ego should not be bruised when there is a need to stop, move back, and rethink when the patient's best interests are at stake. Speed of surgery, in fact, should be the by-product of competence and experience; and not a goal in itself. Time should not be the driver; perfection should be. It must be impressed upon trainees that the duration of surgery, which is a significant predictor of outcome, depends more on appropriate decision making rather than on thoughtless manual dexterity.
The take home message for the trainees is that speed is important but not at the cost of quality. As a surgeon you have to know the trade in your hand and learn the process. You learn through endless repetition until competent surgical skills belongs to you.
| :: References | |  |
| 1. | Kaushal-Deep SM, Ahmad R, Lodhi M, Chana RS. A prospective study of evaluation of operative duration as a predictor of mortality in pediatric emergency surgery: Concept of 100 minutes laparotomy in resource-limited setting. J Postgrad Med 2019;65:24-32.  [Full text] |
| 2. | Mazzocco K, Petitti DB, Fong KT, Bonacum D, Brookey J, Graham S, et al. Surgical team behaviors and patient outcomes. Am J Surg 2009;197:678-85. |
| 3. | Stone JL, Aveling EL, Frean M, Shields MC, Wright C, Gino F, et al. Effective leadership of surgical teams: A mixed methods study of surgeon behaviors and functions. Ann Thorac Surg 2017;104:530-7. |
| 4. | Paediatric Emergency Laparotomy Pathway (PELA) Any Child with Generalised Peritonitis and/or Bowel Obstruction and/or Suspected Appendicitis in Under 5 Years. Central Manchester Hospitals, NHS: UK. |
| 5. | Niitsu H, Hirabayashi N, Yoshimitsu M, Mimura T, Taomoto J, Sugiyama Y, et al. Using the objective structured assessment of technical skills (OSATS) global rating scale to evaluate the skills of surgical trainees in the operating room. Surg Today 2013;43:271-5. |
| 6. | Niitsu H, Hirabayashi N, Yoshimitsu M, Mimura T, Taomoto J, Sugiyama Y, et al. Using the objective structured assessment of technical skills (OSATS) global rating scale to evaluate the skills of surgical trainees in the operating room. Surg Today 2013;43:271-5. |
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